If' 


LIPEMIA    IN    DIABETES 

The  left-hand  tube  shows  the  appearance  of  the  hlood  of 
Case  786  (see  pages  1OO,  2O6,  472)  after'  standing  one-half  hour1; 
the  right-hand  tube  represents  the  blood  as  it  flowed  into  the 
syringe.  Professor'  W.  R.  Bloor  reports  the  following  analysis  of 
the  blood  plasma.  The  blood  was  taken  June  13,  1916,  four-teen 
hour's  after  the  last  meal  and  no  fat  had  been  eaten  for1  the  pre- 
ceding thirty-six  hours:  Fat  (g  1  ycer-icles),  7.2  percent.;  "lecithin," 
O.3  per-  cent.;  cholesterol  (total),  1.7  per  cent. 

Other  analyses;  on  the  same  clay  Allowed:  blood  svujar,  O.27  per  cent.;  blood 
CO_>.  24  mm..  Hg.  tension;  alveolar  air  CO-  ( Fricleri  cia) ,  21  mm.  H<j.  tension; 
urinary  ammonia,  3.2  t)rams;  cliaeetic  acid -p. 

On  , July  7.  IfMii,  tlie  patient  was  sugar-  and  aoid-free.  and  the  blood  su^ar 
amounted  to  O.13  per  cent. 

On  July  1O,  lyiB,  Professor  Bloor  reports  on  the  blood  plasma:  total  fatty 
acids.  O.<)3;  cholesterol  (total),  O.oT;  plasma  praeti(ially  clear. 


THE  TREATMENT 


OF 


WITH  OBSERVATIONS  UPOX  THE  DISEASE  BASED 
UPON  THIRTEEN  HUNDRED  CASES 


BY 

ELLIOTT  P.  JOSLIN,  M.D.  (HARV.),  M.A.  (YALE) 

ASSISTANT    PROFESSOR  OF  MEDICINE,  HARVARD    MEDICAL    SCHOOL;    CONSULTING    PHYSICIAN, 

BOSTON  CITY  HOSPITAL;    COLLABORATOR  TO  THE    NUTRITION  LABORATORY    OF    THE 

CARNEGIE  INSTITUTION  OF  WASHINGTON,   IN  BOSTON 


SECOND  EDITION,  ENLARGED  AND  THOROUGHLY  REVISED 


ILLUSTRATED 


LEA    &   FEBIGEK 

PHILADELPHIA    AND   NEW   YORK 


COPYRIGHT,  LEA  &  FEHI<?ER,   1917 


TO 
THE    MEDICAL    PROFESSION 

OF 

THE    UNITED     STATES    OF    AMERICA 

AND   HER    ALLIES 

UPON    WHOM    DEVOLVES  THE 

TRAINING    OF    THEIR    MILLION    DIABETICS. 


PREFACE  TO  THE  SECOND  EDITION. 


THE  more  than  kind  reception  accorded  the  first  edition  has  led 
me  to  take  even  greater  pains  with  the  second.  The  book  has  there- 
fore been  largely  rewritten,  using  as  a  basis  the  experience  gained 
in  another  year  of  study  of  new  and  old  diabetic  cases.  It  is  now 
possible  to  be  more  definite  in  describing  treatment,  and  this  is 
particularly  true  of  what  is  written  about  acid  poisoning.  Today 
I  can  furnish  facts  in  support  of  my  practice  of  not  giving  alkalis 
in  the  presence  of  threatening  coma.  The  advance  in  the  treat- 
ment of  diabetes,  which  began  with  the  introduction  of  fasting  by 
Dr.  F.  M.  Allen,  continues,  and  statistics  are  now  available  to  show 
it.  vSo-called  acutely  fatal  diabetes  is  disappearing  and  the  first 
year  of  diabetes  is  no  longer,  as  was  only  too  recently  the  case,  the 
diabetic's  danger  zone.  Already  I  have  quite  a' series  of  patients 
who  have  outlived  their  normal  expectation  of  life  at  the  age  of 
onset  of  their  diabetes. 

In  the  additional  120  pages  and  more  of  the  new  edition,  for 
much  in  the  former  edition  has  been  condensed,  I  have  incorpo- 
rated answers  to  questions  raised  by  doctors  and  patients  since  the 
previous  publication  as  well  as  the  conceptions  of  diabetes  now 
uppermost  in  my  mind.  With  this  end  in  view  sixty-one  of  the 
original  illustrative  tables  have  been  revised  and  others  rearranged, 
fifty-nine  new  tables  and  ten  illustrations  have  been  inserted 
and  a  large  amount  of  fresh  material  included.  A  Case  Index  to 
supplement  the  General  Index  and  a  record  of  the  subsequent 
history  of  nearly  all  cases  mentioned  in  the  earlier  edition  increase 
the  value  of  the  volume. 

In  the  United  States  there  are,  I  suppose,  not  far  from  half  a 
million  individuals  with  diabetes  or  destined  to  have  diabetes 
before  they  die.  The  care  of  them  has  devolved  and  will  devolve 
almost  wholly  upon  general  practitioners.  They  are  the  officers 
who  must  train  this  diabetic  army.  Any  method  of  treatment, 
therefore,  to  be  of  maximum  service  must  be  simple  alike  for  physi- 
cian and  patient,  for  the  practitioner  is  a  very  busy  man  and  the 

(v) 


VI  PREFACE    TO    THE    SECOND    EDITION 

patient  must  clearly  understand  the  reasons  for  a  Spartan  life. 
I  have  endeavored  to  keep  these  facts  in  mind  and  I  have  no 
apology  for  my  diabetic's  primer  in  Section  VI. 

The  treatment  of  dialx'tes  today  is  a  serious  problem  not  only  for 
the  patients  themselves  but  for  the  nation  at  large.  The  untreated 
diabetic  is  a  food  spendthrift.  Xo  student  of  diabetes  will  gainsay 
the  statement  that  the  diabetics  in  the  Tinted  States  alone  waste 
food  snfficent  to  supply  the  needs  of  many  thousands  of  individuals 
the  year  round.  If  this  book  helps  to  avert  this  waste,  particularly 
at  this  time,  and  also  benefits  some  of  these  patients,  it  will  have 
accomplished  the  purpose  for  which  is  was  written. 

To  Professor  Francis  G.  Benedict  I  am  under  obligations  in  every 
way,  and  I  can  never  repay  Dr.  Allen's  many  and  continued  kind- 
nesses or  sufficiently  acknowledge  the  inspiration  which  his  fruit- 
ful and  persistent  work  awakens.  So  many  friends  in  Europe 
and  America  have  helped  me  with  my  cases  that  I  cannot  men- 
tion all,  and  it  would  be  invidious  to  name  a  few.  My  appreciation 
of  aid  thus  received  is  best  shown  by  the  adoption  of  suggestions 
offered.  For  this  edition  Dr.  Donald  Van  Slyke  and  Dr.  Reginald 
Fitz,  Professor  Katherine  Blunt,  Professor  Ruth  A.  YYardall  and 
Dr.  T.  M.  Carpenter  have  honored  me  by  the  presentation  of  data 
hitherto  unpublished.  I  am  only  too  glad  to  acknowledge  the  help 
I  have  received  from  many  workers  at  the  Nutrition  Laboratory 
of  the  Carnegie  Institution  and  the  New  England  Deaconess  and 
Corey  Hill  Hospitals.  The  enthusiasm  and  assistance  of  former 
and  present  associates  in  my  work,  Doctors  II.  W.  Goodall,  F.  S. 
Stanwood,  F.  G.  Brigham,  A. -A.  Ilornor,  B.  II.  Ragle,  R.  Ohler, 
and  Horace  Gray  have  never  failed.  The  technical  assistance  of 
Miss  Evelyn  Warren  has  made  it  possible  to  utili/e  modern  chemical 
methods  much  more  widely.  Without  the  cheerful  cooperation  of 
my  secretaries,  Miss  Helen  Leonard  and  Miss  Marjorie  Wood, 
these  pages  could  never  have  been  brought  to  completion.  I  feel 
almost  embarrassed  by  the  kindness  of  Professor  W.  R.  Miles  who 
has  again  read  the  proof. 

The  unfailing  courtesy  and  forbearance  of  my  publishers,  the 
Messrs.  Lea  &  Febiger,  in  the  face  of  many  delays — the  first 
edition  has  been  out  of  print  nearly  seven  months — have  been 
deeply  felt  by  me,  E.  P.  J. 

BOSTON,  1917. 


CONTENTS. 


SECTION  I. 

STATISTICAL  STUDIES  UPON  THE  COURSE  AND  TREAT- 
MENT OF  DIABETES  MELLITUS. 

A.  Diabetes  Mellitus  and  Glycosuria 17 

1.  Diabetes  Mellitus 17 

2.  Physiological  Glycosuria 17 

3.  Alimentary  Glycosuria 17 

4.  Other  Glycosurias 18 

5.  The  Distinction  between  Glycosuria  and  Diabetes       ....  18 

B.  Statistics  Relating  to  Diabetes 19 

1.  Increase  in  the  Incidence  of  Diabetes  Mellitus 19 

2.  The  Explanation  of  the  Statistical  Increase  in  Diabetes    ...  25 

(a)  Greater  Accuracy  of  Vital  Statistics 25 

(6)  More  Frequent  Urinary  Examinations 25 

(c)  General  Increase  in  Duration  of  Life 25 

(<l)  Life  Insurance  Statistics 26 

(e)  Frequency  by  Decades  at  which  Onset  Occurs  Now  and 

Formerly 27 

(/)  The  Importance  of  Recognition  of  the  Extent  of  Diabetes 

in  the  Community,  and  its  Influence  upon  Treatment    .  28 

C.  The  Improvement  in  the  Treatment  of  Diabetes  Mellitus   ....  29 

1.  Indirect  Improvement 29 

(a)  Early  Diagnosis 29 

(1)  Routine  Urinary  Examinations 29 

(2)  Examinations  for  Life  Insurance 30 

(b)  Knowledge  of  Diet  More  General 30 

(c)  The  Disease  is  Better  Understood 31 

(<1)  The  Better  Treatment  of  Complications 31 

2.  Direct  Improvement  Shown  by  Statistics 32 

(«)  Massachusetts  General  Hospital.     1824-1898,  1898-1913, 

1913-101(5 32 

City  of  Boston 34 

Naunyn 35 

Von  Noorden 35 

Author's  Data 35 

(1)  Arranged  According  to  Periods  when  First  Observed, 

Irrespective  of  Previous  Duration 35 


viil  COX  TEXTS 

C.  The  Improvomont  in  the  Treatment  of  Diabetes  Mellitus — 

2.   Direct  Improvement  Shown  by  Statistics — 
(c)  Author's  Data: 

(2)  Duration  of  Life  in  500  Fatal  Cases  of  Diabetes  with 

Actual  and  Percentage  Mortality 36 

(3)  Duration  of  Life  of  040  Living  Cases  of  Diabetes  with 

Actual  and  Percentage  Mortality 37 

(4)  Comparison  of  Duration  of  Life  by  Decade  of  Onset 

of  500  Fatal  and  040  Living  Cases  of  Diabetes      .  37 

D.  Sex 41 

!•:.    Heredity 43 

1.  Earlier  Statistics 4(5 

2.  Notable  Diabetic  Families  Showing  Heredity 40 

3.  The  Favorable  Influence  of  Heredity 47 

4.  Conjugal  Diabetes 49 

5.  Diabetes  in  the  Jewish  Race 49 

F.  The  Curability  of  Diabetes 51 

1.  Acute  Diabetes  Arising  from  Curable  Causes 51 

2.  Exceptional  Cases  in  Childhood ....  52 

3.  Diabetes  Associated  with  Organic  Diseases 53 

G.  Etiology  in  Diabetes 53 

1.  Obesity 53 

2.  Dietary  Excesses 59 

3.  Multiple  Etiology 00 

4.  Heredity 01 

5.  Strenuous  Life 01 

0.  Nervous  Element 01 

7.  Infections 02 

S.  Arteriosclerosis 02 

9.   Syphilis 02 

10.  Trauma 02 

11.  Pancreas .  03 

12.  Hypophysis        ...            ....  03 

13.  Liver 03 

14.  Renal  Glycosuria 03 

15.  Gout 04 

II.  Causes  of  Death  of  Diabetic  Patients  .      .            04 

1.  Deaths  without  Coma 05 

(«)   Miscellaneous      ...            .                         07 

(l>)   Cancer 07 

(c)    Tuberculosis  ....            67 

(il)  Carcliorcnal  and  Vascular 07 

(c)    Infections OS 

(/)    Inanition OS 

2.  Deaths  with  Coma 09 

(a)    Kther  Anesthesia 70 

Impaired  Kidneys 70 

Infections 71 

(<l)    Mental  Excitement .  72 

(<•)    The  Influence  of  a  Fat-protein  Diet 72 

(J)    Rapid  Loss  of  Body  Fluid 73 


CONTENTS  ix 

SECTION  II. 

IMPORTANT  FACTORS  IX  THE  TREATMENT  OF  DIABETES 

MELLITUS. 

A.  Xaunyn's  Conception  of  Diabetes  Mcllitus 74 

B.  Allen's  Hypothesis.   Diabetes — A  Weakness  of  the  Pancreatic  Function  76 

1.  The  Production  of  Diabetes 76 

2.  Pathological  Anatomy  of  Diabetes 76 

3.  Pathological  Physiology  of  Diabetes 76 

C.  Is  the  Tendency  of  the  Diabetic  Glycosuria  to  Increase?      ....  82 

D.  Gain  in  Tolerance  for  Carbohydrates  when  Urine  is  Sugar-free       .      .  84 

E.  Hyperglycemia 87 

F.  Blood  Lipoids 96 

1.  Blood  Lipoids  in  Health 96 

2.  Blood  Lipoids  in  Diabetes 100 

3.  The  Metabolism  of  Fat  in  Diabetes 106 

G.  Total  Metabolism  in  Diabetes  Mellitus 109 

1.  The  Varying  Metabolism  in  Severe  Diabetes 109 

2.  Observations   upon   the    Respiratory   Quotient   in   Health   and 

Diabetes 115 

3.  Observations  upon  the  Pulse 121 

4.  Observations  upon  the  Weight.     Edema 123 

(a)  Water  Content  of  the  Body 124 

(b)  Influence  of  Fat  and  Carbohydrate  Diets  upon  Weight      .  12.5 

(c)  Influence  of  Sodium  Chloride  upon  Weight 126 

(//)  Influence  of  Sodium  Bicarbonate  upon  Weight         .      .      .  127 

(c)   Weights  and  Losses  of  Weight  in  Diabetic  Patients      .      .  128 

(/)   The  Loss  of  Weight  Prior  to  and  during  Coma        .      .      .  129 
(g)   Variations  in  Weight  during   the  First  Week  of   Fasting 

Treatment 129 

5.  Observations  upon  the  Nitrogen  Excretion 130 

6.  The  Storage  of  Carbohydrate  in  Diabetes 134 

(a)  Storage  of  Carbohydrate  as  Glycogen 135 

(6)   Storage  of  Carbohydrate  as  Blood  Sugar 136 

(c)   Influence  of  Rate  at  which  Carbohydrate  is  Administered  138 

((/)  Other  Possible  Storehouses  for  Carbohydrate     ....  139 

(e)   Body  Protein  and  Carbohydrate  Storage 139 

7.  Utilization  of  Carbohydrate  in  Diabetes 140 

(«)  Carbohydrate  Balance 141 

(b)  Weight 141 

(c)  Capacity  for  Storage 142 

((/)  Respiratory  Quotient 142 

0)   Effect  of  Exercise 144 

II.  The  Loss  of  Energy  in  the  Urine  of  Diabetics  in  the  Form  of  Sugar  and 

Acid  Bodies 147 

I.    Glycosuria  is  the  Most  Trustworthy  Symptom    ,            148 


x  CONTENTS 

.1.    The  Nature  of  the  Diabetic  Acidosis  and  Its  Relation  to  Coma     .      .  148 

1.  Acidosis  in  Normal  Individuals 148 

(<i)  Adaptation  of  the  Body  to  a  Non-carbohydrate  Diet  and  to 

Acidosis 154 

(/>)   Source'  of  the  Acid  Bodies 155 

(c)    Percentage  Relation  of  the  Acid  Bodies  to  One  Another    .  155 

((/)   Mode  of  Elimination  of  Acid  Bodies 15(1 

2.  Acidosis  in  Diabetes lot) 

(<i)   Similarity  to  that  in  Normal  Individuals 15(5 

(h)    Extent  of  Acidosis  in  Mild,  Severe  and  Extreme  Cases       .  157 

(r)    Safeguards  of  the  Body  against  Acidosis 1(51 

((/)   Acidosis  Varies  According  to  the  Rapidity  of  Onset,  the 

Age  of  the  Patient  and  Condition  of  the  Kidneys      .      .  It))! 

(e)    Culmination  of  Acidosis  in  Coma, 1(54 


SECTION  III. 

THE  EXAMINATION  OF  THE  URINE,  BLOOD  AND  RESPI- 
RATION IN  DIABETES. 

A.   The  Examination  or  the  Urine 1(55 

1.  The  Desirability  of  Routine  Examinations  of  Urine  of  All  New 

Patients,  and  of  All  Old  Patients  Annually     ....  1(5") 

(n)   Inexpensive  Urinary  Examinations     .      .            .      ...  165 

(h)   The  Importance  of  a  Physician's  Laboratory      ....  1(1(1 

(c)   Causes  which  Lead  to  the  Examination  of  the  Urine  of 

Diabetic  Patients 1(5(1 

(1)  Life  Insurance  Examinations 1(5(5 

(2)  Routine  Examinations 1(17 

(3)  Other  Causes 1(5!) 

2.  The    Mixed    Twenty-four-hour    Quantity    of    Urine    Should    be 

Examined 1(5!) 

I}.  The  Volume  of  Urine  in  Twenty-four  Hours 1(59 

4.  The  Specific  (Iravity 17)3 

f).  Tests  for  (Uucose 174 

(«)  Qualitative  Tests 174 

(1)  Fehling's  Test 175 

(2)  Benedict's  Test    . 175 

(':*)    Eolin's  Test 17(1 

(h)  Multiple  Qualitative  Tests 177 

(c)   Quantitative  Tests 178 

(1)  Fermentation  Test 178 

(2)  Polariscopy 17(J 

(3)  Fehling's  Test             170 

(4)  Benedict's  Test 180 

(5)  Peters's  Test         18:* 

6.  Tests  for  Other  Sugars 18.'i 

(a)    Lactose     .              18.S 

(h)    Pentose 184 

(c)    Levulose 184 


CONTENTS  xi 

A.  The  Examination  of  the  Urine — 

6.  Tests  for  Other  Sugars: 

(d)  Maltose 184 

(e)  Glycuronic  Acid 184 

(/)    Substances  Found  in  the  Urine  which  Give  Rise  to  (Jon- 
fusion  in  Testing  for  Sugar 185 

7.  Methods  for  the  Determination  of  the  Urinary  Acid    ....  18.5 

(a)  Qualitative  Tests 185 

(1)  Diacetic  Acid 185 

(2)  Acetone 18G 

(3)  /3-oxybutyric  Acid LS6 

(b)  Quantitative  Tests 186 

(1)  Reaction  of  Urine 187 

(2)  Ammonia 188 

(3)  /3-oxybutyric  Acid 190 

(4)  Acetone  and  Diacetic  Acid 191 

8.  Nitrogen 198 

9.  Albumin 200 

10.  Casts 200 

11.  Chlorides 201 

B.  The  Examination  of  the  Blood 202 

1.  Blood  Sugar 203 

(«)  Lewis-Benedict  Method 203 

(b)  Bang's  Method 204 

(c)  Other  Methods 200 

2.  Lipoids 206 

3.  Non-protein  Nitrogen 208 

(a)  Determination    of     Non-protein     Nitrogen    in    Blood    by 

Titration 211 

4.  Chlorides 212 

5.  Acetone  in  the  Blood 214 

(«)   Wishart  Method  for  Detection  of  Acetone  in  the  Blood     .  214 

(b)  Van  Slyke-Fitz  Methods  for  Determination  of  /3-hydroxy- 

butyric  Acid,  Diacetic  Acid  and  Acetone  in  Urine  and 

Blood 214 

6.  Carbon  Dioxide  in  Blood  Plasma             214 

(n)  Van  Slyke's  Method  for  Determination  of  Carbon  Dioxide 

Capacity  of  Blood  Plasma 217 

7.  The  Hydrogen-ion  Concentration  of  the  Blood 221 

8.  Titratable  Alkalinity  of  the  Blood 222 

9.  Total  Solids 223 

C.  Th"  Examination  of  the  Respiration 223 

1 .  The  Technic 223 

2.  The  Respiratory  Quotient 225 

3.  The  Total  Metabolism 227 

4.  The  Non-protein  Respiratory  Quotient 229 

5.  Theoretical  Respiratory  Quotients  as  Calculated  from  the  Diet  .  230 

6.  The  Carbon  Dioxide  Tension  of  the  Alveolar  Air 231 

(a)  Fridericia  Method 233 

(6)   Marriott's  Method 237 


xii  CONTENTS 

SECTION  IV. 
THE  DIET  IN  HEALTH  AND  IN  DIABETES. 

A.  The  Diet  of  Normal  Individuals 240 

1.  Caloric  Needs  of  the  Body 240 

2.  Composition  of  the  Diet 243 

3.  Carbohydrate 244 

4.  Protein 245 

5.  Fat 247 

0.  Caloric  Values  which  Every  Doctor  Should  Know  by  Heart         .  249 

B.  The  Diet  of  Diabetic  Individuals 251 

1.  Caloric  Needs  of  the  Diabetic '251 

2.  Carbohydrate 254 

(ft)  Assimilability  of  Starch  and  the  Various  Sugars      .      .      .  254 

(1)  Clucose 250 

(2)  Saccharose 258 

(3)  Lactose 258 

(4)  Maltose 258 

(5)  Levulose 258 

(0)  Calactose 258 

(7)  Inulin 259 

(b)  The  Estimation  of  the  Carbohydrate  in  the  Diabetic;  Diet  259 

(c)  Carbohydrate  in  Vegetables:  Loss  in  Cooking  .      .      .      .  259 

(1)  Potatoes 203 

(2)  Nuts 204 

(3)  Fruit 204 

(4)  Oranges 204 

(5)  Bananas 200 

(0)   Ripe  Olives 200 

(7)  Milk 207 

(8)  Oatmeal 207 

(9)  Bread 207 

3.  Protein • 207 

Meat  and  Fish 270 

Broths 271 

Increased  Assimilability  of  Carbohydrate  in  Absence  of 

Protein 273 

(d)  Dextrose-nitrogen  Ratio 274 

(<>)   The  Carbohydrate  Balance 275 

4.  Fat 270 

(a)  The  Increased  Assimilability  of  Carbohydrate  in  Absence 

of  Fat 277 

(b)  The  Value-  of  Fat  to  the  Diabetic 277 

(c)  The  Danger  of  Fat  to  the  Diabetic 281 

5.  Alcohol 282 

0.  Liquids    ....  283 

7.  Sodium  Chloride 283 

8.  Lime  Deficiency  in  Diabetes 285 


CON  TENT  8  xiii 

SECTION  V. 

TREATMENT. 

A.  Prophylaxis 286 

1.  Early  Diagnosis 287 

2.  Heredity 287 

3.  Obesity 288 

4.  Infectious  Diseases 288 

5.  Pregnancy 289 

6.  Hygiene 289 

(a)  Physical  Hygiene 289 

(b)  Mental  Hygiene 290 

7.  Syphilis 292 

8.  Pancreatic  Preparations 294 

9.  Surgery 295 

B.  Classification 297 

1.  Classification  for  Treatment 297 

2.  Classification  for  Prognosis 299 

C.  Dietetic  Treatment 299 

1.  General  Discussion 299 

2.  Author's  Plan  of  Campaign  against  Diabetes 304 

3.  Summary  of  Dietetic  Treatment 305 

4.  Details  of  Treatment 307 

(a)  Preparation  for  Fasting 307 

(b)  Fasting 311 

(c)  Intermittent  Fasting 313 

((/)  Determination  of  Tolerance  for  Carbohydrate   ....  317 

(c)    Determination  of  Tolerance  for  Protein 31g 

(/)    Determination  of  Tolerance  for  Fat 320 

(g)  The  Caloric  Needs  of  the  Patient 321 

(1)   Lost  Calories 322 

(//)  Reappearance  of  Sugar 323 

(i)    Weekly  Fast  Days 323 

5.  The  Management  of  Mild  Cases  of  Diabetes 324 

6.  The  Management  of  Severe  Casos  of  Diabetes 325 

D.  Follow-up  Methods 327 

E.  Summaries  of  the  Treatment  Employed  in  Three  Successive  Groups 

of  Cases 328 

1.  Loss  of  Body  Weight 329 

2.  Loss  of  Body  Protein 335 

3.  Total  Calories 335 

F.  The  Fatal  Cases  of  1916 336 

1.  Deaths  without  Coma 338 

(a)  Miscellaneous 338 

(1)  Inanition 338 

(b)  Cancer 341 

(c)  Tuberculosis 341 

('/)  Cardiorenal  and  Vascular 341 

(e)   Infections  341 


xiv  CONTENTS 

F.  The  Total  Cases  of  1916: 

2.   Deaths  from  Coma 342 

(a)  and  (b)   Diabetes  Untreated  and   Neglect  of   Preparatory 

Treatment 313 

(c)  Obesity.      High  Fat  and  Low  Carbohydrate       ....  344 

(d)  Treatment  Abandoned 3-17 

(r)   Imperfect  Supervision    ....  349 

(/)    Increasing  Severity  of  Diabetes 349 

(&)    Ether        .      .  .  350 

(//..)    Carbuncle     ...  350 

G.  Cases  Unsuccessfully  Treated  by  Fasting 350 

1.  Deatli  Caused  by  the  Inauguration  of  Fat -protein  Diet  in  a  Child  350 

2.  Intercurrent   Infections       .  352 

3.  Diabetes  of  Long  Duration 358 

4.  Cardiorenal  ('(implications 362 

5.  Syphilis 304 

II.  Special  Dietetic  Methods 304 

1.  Fasting  Days 304 

2.  Vegetable  Days 307 

3.  The  Oatmeal  Treatment 307 

(a)   The  Place  of  Oatmeal  in  Present  Diabetic  Therapy       .       .  375 

4.  Other  Carbohydrate  Cures 370 

(a)   Wheat 370 

(h)    Potatoes 370 

(c)    Bananas 377 

(<l)  The  Milk  Cure 377 

(c)  Levuloso 378 

5.  Rectal  Injections  of  Sugar 385 

I.     The  Treatment  of  Acid  Intoxication  and  Diabetic  Coma     ....  387 

(a)  Improvement  in  the  Toleration  for  Carbohydrates       .      .  391 

(h)   Elimination  of  .the  Source  of  Supply  of  Acid  Bodies     .      .  392 

(c)  Administration  of  Substances  which  Favor  the  Combustion 

of  Acid  Bodies  392 

(d)  Dangers  of  Alkalis 394 

(f)    Importance  of  Liquids 397 

.1.    The  Conservation  of  Energy  in  the  Diabetic  Individual       ....  398 

K.   The  Use  of  Drugs ....  399 

L.    The  Treatment  of  Complications 402 

1.  Infectious  Diseases 402 

(a)  Pneumonia 403 

2.  Tuberculosis 404 

3.  Arteriosclerosis.      Bright 's  Disease 413 

4.  Gangrene 423 

5.  Care  of  the  Skin.     Pruritus,  Furunculosis,  ( 'arbuncles       .       .       .  427 
(I.  Care  of  the  Teeth 430 

(a)  Death  Subsequent  to  Extraction  of  Teeth:  Ether  Anesthesia  431 

7.  ( 'oust  ipat  ion  and  Diarrhea 433 

8.  Neuritis 430 

9.  Eyesight 437 


CONTENTS  xv 

M.  Surgery  and  Diabetes 438 

1.  Elements  Predisposing  to  Surgical  Failure 438 

(a)  Acid  Intoxication 439 

(t>)   Slow  Healing  of  Wounds 439 

(c)   Exhaustion 439 

((/)  Lack  of  Exercise 439 

2.  Elements  Favoring  Surgical  Success 439 

(a)  Good  Medical  Care 440 

(/>)   Anesthesia 441 

(c)  The  Introduction  of  Aseptic  Methods 445 

(d)  The  Avoidance  of  Trauma 445 

3.  Results 445 

N.  Pregnancy  and  Diabetes 448 

1.  Cases  of  Pregnancy  Showing  Large  Quantities  of  Sugar    .      .      .  449 

2.  Conclusions  upon  Pregnancy  and  Diabetes 454 

3.  Notable  Increase  in  Tolerance  for  Carbohydrate  during  Pregnancy  455 

O.    Diabetes  in  Children 458 

P.    Diabetes  in  Old  Age 46(> 

Q.   Cases  of  Diabetes  of  Fifteen  or  More  Years'  Duration 408 


SECTION  VI. 

AIDS  IN  THE  PRACTICE  AND  MANAGEMENT  OF  DIABETIC 

CASES. 

A.   What  Every  Diabetic  Should  Know 470 

1.  The  Nature  of  Diabetes 470 

2.  Faithful  Treatment  Accomplishes  Much 470 

3.  Success  Depends  upon  the  Patient 471 

.4.   Diabetes:     The  Best  of  the  Chronic  Diseases 471 

5.  A  Sugar-free  Urine  Spells  Improvement 471 

6.  Treatment  Depends  upon  Diet  and  not  Drugs 471 

(o)  Carbohydrate 471 

(b)  Protein  and  Fat .471 

(c)  Weights  and  Measures  Employed  in  Computing  the  Diet  472 

((/)  The  Quantity  of  Food  Required 473 

(c)   Calories 473 

(/)    The  Normal  and  Diabetic  Diets  Compared         ....  473 

(g)  Observe  the  Method  of  Making  the  Urine  Sugar-free   .      .  473 

(/O  Distribution  and  Exchange  of  Carbohydrates     ....  474 

(z)    Special  Dietetic  Rules  and  Hints 474 

7.  Care  of  Teeth 474 

8.  Care  of  Skin 474 

9.  Treatment  of  Constipation 475 

10.  Exercise 475 

11.  Rest 475 

12.  Sleep 475 

13.  Examination  of  Urine 475 

14.  Test  for  Sugar 475 

15.  Visit  to  the  Doctor  476 


XVI  CONTENTS 

B.  Directions  for  Nurses  in  Charge  of  Diabetic  Patients 476 

C.  Diabetic  History  Chart  for  the  Use  of  Institutions  and  of  Physicians 

Especially  Interested  in  Diabetes 480 

D.  Chart  for  Dietary  and  Urinary  Records 481 

E.  Actual  Diets  Employed  to  Render  Patients  Sugar-  and  Acid-free. 

Dietary  and  Urinary  Charts 484 

1.  Diet  of  a  Child  Twelve  Years  Old.     Case  No.  923.     Acidosis      .  484 

2.  Diet  of  a  Child  Two  Years  Old.     Case  No.  938.     No  Acidosis    .  48.1 

3.  Diet  of  a  Woman  Fifty-five  Years  Old.     Case  No.  759.     Acidosis. 

Duration  of  Diabetes  Fifteen  Years 489 

4.  Diet  of  a  Man  Fifty-five  Years  Old.      Case  No.  181.     Marked 

Acidosis.     Duration  of  Diabetes  Eleven  Years.     Intermittent 
Fasting-     Urine  Free  from  Sugar  and  Acid  in  Thirty-six  Days     492 

F.  Hospital  Treatment 493 

G.  Ambulatory  Treatment 500 

II.  Specimen  Leaf  of  a  Book  Constructed  to  Facilitate  the  Recording  of 

Diabetic  Statistics 501 


SECTION  VII. 

FOODS  AND  THEIR  COMPOSITION. 

A.  Diabetic  Foods 503 

1.  Substitutes  for  Bread 505 

(«)   Bran  Bread ....  505 

(b)  Gluten  Bread 50(5 

(c)  Light  Breads 50(5 

(d)  Various  Other  Substances 506 

2.  Substitutes  for  Milk 507 

B.  Composition  of  American  Food  Materials 508 

C.  Foods  and  Their  Carbohydrate  Content 511 

D.  Composition  of  So-called  Diabetic  Foods 519 

E.  Dietetic  Suggestions,  Recipes  and  Menus 530 

Seven  Menus  for  a  Severe  Diabetic 535 

Inexpensive  Menus 539 

F.  Tables  of  Equivalents 542 


SECTION  I. 

STATISTICAL  STUDIES  UPON  THE  COURSE  AND 
TREATMENT  OF  DIABETES  MELLITUS. 


A.     DIABETES  MELLITUS  AND  GLYCOSURIA. 

1.  Diabetes   Mellitus. — Definition. — Definitions  of    diabetes  are 
unsatisfactory,  but  it  is  safe  to  say  that  diabetes  is  a  disease  in 
which  the  normal  utilization  of  carbohydrate  is  impaired,  in  con- 
sequence of  which  glucose  is  excreted  in  the  urine.    My  rule  in  the 
treatment  of  diabetes  is  to  consider  any  patient  to  have  diabetes 
mellitus  and  treat  him  as  such,  until  the  contrary  is  proven,  who 
has  sugar  in  the  urine  demonstrable  by  any  of  the  common  tests. 
This  method  of  procedure  is  safer  for  the  patient  than  to  make 
use  of  the  term  glycosuria,  which  begets  indifference  (see  p.  2S(>). 

2.  Physiological   Glycosuria. — Sugar,   meaning   thereby   glucose 
(dextrose,  ("6IIi-.>O6),  is  a  normal  constituent  of  the  urine,  occurring 
in  varying  quantities.     Folin1  was  able  by  means  of  his  technic  to 
demonstrate  the  presence  of  sugar  in  nearly  one  hundred  tests  made 
on  the  urines  of  normal  persons,  and  he  adds :  "  The  amount  of  sugar 
present  in  normal  human  urine  is  therefore  probably  much  greater 
than  is  indicated  by  the  negative  findings  recorded  on  the  basis  of 
the  clinical  qualitative  tests  for  sugar  in  current  use."     Myers,2 
in  a  recent  publication  concludes  that  normal   urine  appears  to 
contain  between  0.08  and  0.2  per  cent,  sugar.    He  used  a  method  of 
analysis  similar  to  that  employed  by  Benedict  and  Lewis  for  the 
estimation  of  sugar  in  the  blood.    On  the  other  hand,  the  Benedict 
test  is  seldom  found  too  delicate,  although  its  author  maintains 
that  according  to  his  later  technic  (see  p.  17"))  he  can  detect  glucose 
in  as  low  concentration  as  0.01  to  0.02  per  cent.,  providing  the  urine 
is  of  low  dilution.     Therefore  it  would  seem  quite  impossible  to 
demarcate  sharply  between   normal   and   pathological  urines  with 
reference  to  the  sugar  output. 

3.  Alimentary  Glycosuria. — The  sugar  may  appear  in  the  urine 
after  a  meal  rich  in  carbohydrates.     If  the  carbohydrates  are  in 

'•  Fnlin:  Jour.  Biol.  f'lieni.,  191"),  xxii,  p.  327. 

2  Myers:  Proc.  Soc.  Exp.  Biol.  and  Mod.,  1911),  xiii,  p.  17-V 

2  (17; 


IS  DIABETES   MELIJTTS 

the  form  of  starch  (alimentary  glycosuria  e  ainylo)  it  would  .signify 
diabetes  mellitus,  but  if  the  carbohydrates  are  in  the  form  of  sugar 
(alimentary  glycosuria  e  saccharo)  it  might  or  might  not  signify 
diabetes.  To  determine  this  point  Xaunyn1  suggests  the  admin- 
istration of  100  grams  of  dextrose  two  hours  after  a  breakfast  of 
a  large  cup  of  coffee  and  milk  and  80  to  100  grams  of  bread.  Jf 
sugar  is  then  demonstrable  in  the  urine  in  a  quantitatively  estimable 
amount,  diabetes  mellitus  exists. 

4.  Other  Glycosurias. — The  drug  glycosurias  and  those  of  trau- 
matic and  emotional  origin  are  almost  invariably  of  a  temporary 
nature,  so  that  doubt  concerning  the  diagnosis  of  diabetes  mellitus 
vanishes  when  sugar  is  constantly  found  in  the  urine. 

5.  The    Distinction    between    Glycosuria   and    Diabetes. —  The 
great  variety  of  conditions  under  which  sugar  appears  in  the  urine 
has  been  discussed  in  detail  by  Xaunyn,  and  more  recently  by 
Allen.'2     In  this  latter  volume  diabetes  and  the  allied  glycosurias 
are  approached  from  a  refreshingly  new  stand-point.    Allen  proposes 
two  laws  by  which  glycosuria  can  be  distinguished  from  diabetes. 
The  first  follows: — Allen's  Paradoxical  Laic — "Whereas  in  normal 
individuals  the  more  sugar  is  given  the  more  is  utilized,  the  reverse 
is  true  in  diabetes."     Allen  shows  that  the  limits  of  tolerance  in 
non-diabetic  animals  are  all  apparent,  not  real.     Xo  real  limit  of 
the  power  of  utilization  of  sugar  exists  except  death.     This  law 
applies  to  all  species  of  animals  which  have  been  tested,  to  all 
methods  of  administering  sugar,  and  to  all  sugars  and  carbohydrates, 
provided  they  are  utilized  at  all.    This  paradoxical  law  of  dextrose 
sharply   distinguishes   diabetic  animals   from   every  type   of   non- 
diabetic  animals.     In  diabetic  animals  the  limits  of  tolerance  are 
real  and  not  apparent.     In  totally  diabetic  animals  the  injection 
of  dextrose  causes  an  excretion  of  glucose  not  only  equal  to  but 
frequently  greater  than  the  doses  injected.     In  milder  diabetics 
not  only  is  the  proportion  of  excretion  to  injection  generally  high, 
but  the  assimilation  may  be  made  worse  instead  of  better  by  an 
overdose— just   the   opposite    of   the    paradoxical    law.      This    law 
enables  distinctions  to  be  drawn  experimentally  between  diabetes 
and   nervous  glycosuria,   whether  of  organic  or  functional   type. 
Kvery  form  of  non-diabetic  glycosuria  retains  the  power  of  utilizing 
dextrose  in  amounts  increasing  with  the  dose. 

This  law  proves  that  the  lowering  of  tolerance  in  diabetes  is 
totally  different  from  the  lowering  of  tolerance  in  other  conditions; 
that  diabetes  is  not  a  simple  overproduction  of  sugar,  and  herein 
lies  the  chief  value  of  Allen's  conception  because  it  has  been  experi- 
mentally proven  that  where  there  is  a  simple  overproduction  of 
sugar  the  paradoxical  la\v  holds.  It  shows  that  diabetes  is  not 

1  Xaunyn:  Der  Diabetes  Melilus,  Wien.  1!)()G.  p.  .'17. 

'-Allen:  ( llyrosuria  and  Diabetes,  1'JKi,  Harvard  University  Press. 


STATISTICS   RELATING   TO   DIABETES  19 

explained  by  an  excess  of  renal  permeability,  by  overaction  of 
certain  glands,  or  by  states  of  the  nervous  system,  either  functional 
or  organic,  which  may  be  accompanied  by  glycosnria. 

Earlier  investigators  as  well  as  Allen  were  able  to  show  that  all 
common  sugars  are  antidinretics,  and  diminish  the  output  of  urine. 
In  other  words,  as  respects  diuresis,  these  sugars  when  given  intra- 
venously obey  the  laws  of  crystalloids,  and  when  given  otherwise 
obey  the  laws  of  colloids.  Salts  and  other  diuretics  have  a  rather 
similar  diuretic  action  by  all  modes  of  administering,  when  allow- 
ance is  made  for  the  rate  of  absorption.  In  diabetes  this  difference 
is  abolished  as  respects  dextrose.  In  diabetes,  dextrose  acts  as  a 
diuretic  when  it  is  given  intravenously,  orally,  subcutaneously,  or 
otherwise.  In  other  words,  it  obeys  the  diuretic  laws  of  a  salt. 
This  is  Allen's  second  differential  test  between  diabetes  and  glyco- 
suria  but  whether  it  will  hold,  Woodyatt's1  recent  work  on  the  rate 
of  intravenous  assimilation  of  glucose  makes  it  doubtful.  The  further 
development  of  his  researches  along  this  line  is  awaited  with  interest. 
It  appeared  to  Allen  that  dextrose  exists  in  the  normal  body  in  a 
state  of  colloid  combination;  as  a  colloid  it  is  utilized  by  the 
tissues,  and,  like  other  colloids,  diminishes  diuresis.  It  assumes 
the  colloid  form  in  passing  through  any  living  membrane,  never 
circulating  in  crystalloid  form  in  the  normal  organism  except 
after  direct  intravenous  injection.  On  the  other  hand,  in  the 
diabetic  organism  dextrose  circulates  as  a  free  or  very  poorly  com- 
bined crystalloid,  and  in  this  state  is  not  available  to  the  tissues 
and  is  a  diuretic  like  every  crystalloid. 

Allen  also  concludes  that  the  sugar  of  the  normal  body  is  com- 
bined with  some  substance  in  colloid  form  which  makes  it  available 
to  the  tissues.  This  combining  substance  he  refers  to  as  an  ambo- 
ceptor.  When  the  pancreas  is  absent  or  insufficient,  dextrose  occurs 
free,  and  he  therefore  assumes  that  this  combining  substance  is 
furnished  by  the  pancreas,  and  accordingly  used  the  term  "pan- 
creatic amboceptor"  synonymously  with  the  "internal  secretion 
of  the  pancreas."  Allen  defines  diabetes  as  deficiency  of  pancreatic 
amboceptor. 

B.     STATISTICS  RELATING  TO  DIABETES. 

1.  Increase  in  the  Incidence  of  Diabetes  Mellitus. — If  diabetes 
should  continue  to  increase  in  the  next  thirty  years  at  the  same 
rate  statistics  show  it  has  increased  in  the  last  thirty  years  it  would 
rival  tuberculosis  as  a  cause  of  death,  and  if  this  rate  progressed  for 
another  generation  diabetes  would  be  responsible  for  almost  the 
entire  mortality  of  the  world.  Such  a  rapid  rate  of  increase  is  evi- 

1  Woodyatt,  Sansum  and  Wilder:  Jour.  Am.  Mecl.  Assn.,  1915,  Ixv,  p.  21)07;  see 
also  p.  255,  below. 


20  DIABETES  MELLITUS 

deuce  of  itself  that  a  fallacy  exists  somewhere  in  the  statistics. 
Convincing  proof  that  this  is  the  case  is  furnished  by  u  comparison 
of  the  statistics  for  the  registration  area  of  the  United  States  (luring 
the  years  1010,  1911,  1012,  and  1913,  because  during  these  years 
the  death-rate  for  diabetes  was  nearly  stationary.  Such  a  sudden 
halt  in  the  progressive  frequency  of  the  disease  could  not  have 
been  brought  about  without  some  obviously  remarkable  improve- 
incMit  in  treatment,  preventive  or  otherwise.  This  we  know  did 
not  take  place  in  1910.  This  striking  interruption  in  the  advancing 
incidence  of  the  disease  is  also  indicated  by  the  statistics  of  New 
York  and  Boston.  Thus,  in  Boston  during  1912  and  1913  the 
death-rate  from  diabetes  was  less  than  during  1910  and  1911.  lint 
since  1913  a  remarkable  advance  is  registered  throughout  the 
country  and  in  New  York  and  Boston  as  well.  This  rapid  rise  in 
mortality  in  1914,  191")  and  191(>  1  believe  attributable  to  the 
increased  attention  devoted  to  this  disease  by  the  medical  pro- 
fession and  the  newspapers  following  the  announcement  of  a  new 
method  of  treatment. 

The  following  tables  illustrate  the  rapid  statistical  increase 
in  the  frequency  of  diabetes  and  the  acceleration  of  the  increase 
which  this  has  recently  undergone: 

TAHLE   1. — THE  REGISTRATION  AREA  OF  THE  TNITED  STATES. 

Deaths  from  all  causes.1  Deaths  from  Diabetes. 
Kate  per  Hate  per 

1000  100,000 

Census  year.2  Xumbcr.  population.  Number.        population. 

1880 169,453  19.8  237  2.8 

1X90 380,212  19.0  1089  5.5 

1900 512,009  17.8  2093  9.3 

TABLE  2. — THE  REGISTRATION;  AUKA  OF  THE  UNITED  STATES. 

Deaths  from  diabetes. 
Kate  per 
100.000 
Number.         population. 

2,990  9  7 

3,212  10  2 

3,312  10  3 

3,081  11.3 

4,259  12  8 

4,397  12.9 

5,3;^  12.7 

5,801  13  5 

0,274  13  1 

7.024  13  8 

8,040  14.9 

8.S05  11.9 

9.045  15.0 

9,000  15.3 

10.000  10.2 

11,775  17.5 


Calendar  year. 

Number. 

population. 

1900     .       .       . 

.      .    539,  «.  139 

17.0 

1901      .       .       . 

.      .     518,207 

10.5 

1902     .       .       . 

.      .     508,040 

15.9 

1903     .       .       . 

.      .     524,415 

100 

1904     .       .      . 

.      .     551,354 

10.5 

1905 

545  53:', 

10.0 

1900 

058  105 

15.7 

1907     .       .       . 

.     087,034 

10.0 

1908 

091  574 

14  8 

1909     .       .      . 

.       .     732,538 

14.4 

1910     .       .      . 

.      .     805,112 

15.0 

191  1 

839  2X4 

14.2 

1912     .       .       . 

.       .     83X.251 

13.9 

191:5'   .      .      . 

.     890.848 

14.1 

1914    .      .      . 

.     89X.059 

1:5.0 

1915     . 

.     909.155 

1  3  .  5 

"The    rouiMnition    urea    for    I'.M  ...    , 

population  of  the  L'nited  State's,  for  l'.)14,  0(i.,s  per  cent.,  and  for  I'.U,},  (17.1  pei 


STATISTICS  RELATING   TO  DIABETES 


21 


In  Fig.  1  are  displayed  the  falling  rate  of  deaths  from  all  causes 
per  1000  and  the  rising  rate  of  deaths  from  diabetes  per  100,000 
during  the  last  thirty-five  years  in  the  registration  area  of  the 
United  States. 

Disregarding  the  figures  for  the  death-rate  from  diabetes  prior 
to  1900  as  quite  inaccurate,  it  will  be  seen  that  the  mortality  from 
the  disease  in  the  registration  area  of  the  United  States  has  increased 
statistically  between  1900  and  1915  by  80  per  cent.,  whereas  there 
has  been  a  decrease  of  24  per  cent,  in  deaths  from  all  causes. 


1880 


ISO!) 


1910 


1915 


Fui.  1. — The  falling  rate  of  deaths  from  all  causes  per  1000  and  the  rising  rate 
of  deaths  from  diabetes  per  100,000  between  the  years  1880  and  1915  in  the  regis- 
tration area  of  the  United  States. 

1  believe  that  this  increase  will  continue  to  occur  for  a  good 
many  years  to  come,  and  in  fact  until  examinations  of  the  urine  of 
each  individual  in  the  community  are  made  not  only  with  each 
illness,  but  also  once  or  twice  yearly.  Certainly  until  that  time  is 
reached,  the  statistical  increase  in  diabetes  must  be  explained 
simply  on  the  ground  of  more  accurate  diagnosis. 

Save  for  the  diseases  of  the  arteries,  diabetes  has  increased  more 
rapidly  as  a  cause  of  death  in  the  registration  area  of  the  United 
States  in  the  first  decade  of  this  century  than  cancer,  cerebral 
hemorrhage  and  apoplexy,  organic  diseases  of  the  heart,  cirrhosis 
of  the  liver  or  B right's  disease.1 

During  the  last  thirty-five  years  the  general  death-rate  of  New 
York  City  has  been  cut  in  half,  but  the  death-rate  from  diabetes 
has  increased  statistically  sixfold.  (See  Table  3.) 

1  Dublin:    Popular  Science  Monthly,  April,  1915,  Ixxxvi,   p.  313. 


22 


DIABETES  MELLITUS 


TABLE  3. 


1SSO 
1X00 
1000 
1010 
1011 
1012 
1013 
1014 
1015 
1010 


Total 

Old 

City.' 
31,037 
40,103 
43,227 
45,02.8 
45,324 
43,102 
43,1X0 
44,171 
43,704 
43,407 


70,872 
70,742 
75,423 
73.00S 
73,002 
74,  so:; 
70,103 
77,soi 


3.  —  XEW  YORK 

CITY. 

Death-rate 

per  1000 
Old         Creator 
City.          City. 
20  .1 

Deaths  from  diabetes. 
Number.        Kate  per  100,000. 
Old     Creator      Old          Greater 
City.      City.        City.           City. 
44          .  .            3  .  0 

21 

.0 

130 

X 

.0 

21 

.0 

20 

.  0 

233 

357 

11 

3 

10 

,4 

10 

.4 

16 

.0 

440 

70S 

10. 

0 

10 

0 

15 

.  S 

15 

1 

421 

730 

14 

7 

14 

8 

It 

.0 

14 

.1 

521 

870 

17 

,-> 

16 

8 

14 

4 

14 

2 

500 

8S4 

16 

0 

17 

0 

14 

4 

11. 

0 

540 

070 

17 

8 

is 

3 

14 

,0 

13. 

0 

000 

1100 

19 

3 

20 

2 

13, 

G 

13. 

0 

050 

1118 

20. 

2 

20 

,0 

Boston  shows  a  higher  mortality  from  diabetes  than  any  city 
with  which  I  am  acquainted  save  Berlin.  It  will  be  of  the  greatest 
interest  statistically  to  note  if  the  mortality  in  other  sections  of 
the  community  continues  to  approach  the  level  reached  here.  To 
a  certain  extent  the  city  with  the  highest  mortality  serves  as  an 
index  to  which  the  mortality  in  other  communities  may  be  expected 
to  rise. 

TABLE  4. — BOSTON. 

Deaths  from  diabetes. 
Deaths,  from        Death-rate 
diabetes. 

31 
77 
135 
138 
136 
138 
144 
195 
193 


Dentlis  from 

all  causes. 

Deaths, 

Death-rate 

all  causes. 

per  1000. 

1880    . 

.      .        8,531 

23.51 

1890    .      . 

.      .      10,181 

22  .  66 

1900     .      . 

.      .      11,678 

20  .  80 

1910     .      . 

.      .      11,574 

17.20 

1911     .      . 

.      .      11,767 

17.22 

1912     .      . 

.      .      11,643 

16.34 

1913 

1  1  839 

16  .  34 

1914     .      . 

.      .      11.831 

16.06 

1915 

12  01  S 

1  6  .  06 

1916     . 

12,776 

16.80 

6.90 
13.71 
20.07 
20 . 20 
19.09 
19.05 
19.55 
26 . 06 
25 . 38 


TABLE  5. — BERLIN. 3     DEATHS  FROM  DIABETES  PKH  100,000. 


Males. 

Females. 

Total. 

1871-1875  .... 

.        .        .        .          2.2 

1.2 

1.7 

1876-1880  .... 

.      .      .      .        4.0 

2.0 

3.0 

1881-1885  .... 

.      .      .        4.7 

2.6 

3  .  6 

1886-1890  .... 

.      .      .      .        6.3 

3.9 

5.1 

1891-1895  .... 

.      .      .      .        9.4 

5  .  5 

7.4 

1896-1900  .... 

.      .      .      .      11.7 

7.1 

9.3 

1901-1905  .... 

.      .      .      .      20.4 

12.4 

16.2 

1906-1910 

.      .                  23  4 

14.8 

IS  9 

1911       

.      .      .      .      25.2 

17.6 

21.3 

1912 

24.8 

19.5 

22.0 

The  effeet  of  the  limited  rations  incidental  to  the  European 
War  upon  the  frequency  of  diabetes  in  Europe  will  surely  be  striking. ' 

1  Old  C'ity  of  Xew  York  includes  present  boroughs  of  Manhattan  and  the  Bronx. 

1  ( I  renter  ( 'ity  of  Xew  York  includes  all  boroughs. 

'•'  The  data  for  the  two  periods  1S71  1S75  and  1x70- 1SSO  were  obtained  from 
von  Xoorden,  Die  Zuekerkrankheit,  Berlin,  1012.  p.  55;  the  remaining  figures  were 
kindly  furni.-hod  me  l>y  Mr.  Samuel  1..  Ko<_'er>,  I  tirector  of  the  Bureau  of  the  C'ensus, 
Washington.  See  "Die  ( leslorhenen  nach  Todesursaehen "  in  the  Statist  isclies 
Jahrhueli  der  Stadt  Berlin,  vols.  ix  to  xxxii  and  vol.  xxxii,  p.  1,  for  "Mittlere  Bevol- 
keruiiK  nach  dem  Ceschleeht  von  1x10  l>is  1011;"  also  "Taliellen  iiber  diu  Bevolker- 
unfrsvorfiaiifie  Berlins"  for  1010  and  1011. 

•'  GottsAein  and  Unibev:  Jour.  Am.  Med.  Assn.,  1917,  Ixvii,  p.  70. 


STATISTICS  RELATING   TO  DIABETES  23 

In  Paris,  too,  the  increase  of  deaths  caused  by  diabetes  is  evident 
and  T  am  indebted  to  Air.  Samuel  L.  Rogers,  Director  of  the  Bureau 
of  the  Census  for  the  statistics  in  Table  (>. 

The  table  shows  the  deaths  from  diabetes  per  100,000  in  Paris 
in  each  of  the  years  between  1880  and  1912,  both  inclusive. 

TABLE  G. — PARIS.     DEATHS  FROM  DIABETES  PER  100,000. 

1880  ...       6.3  1891  .  .  .     12.9  1902  .  .  .     14.6 

1881  .      .      .       6.8  1892  .  .  .     12.4  1903  .  .  .     15.1 

1882  ...       7.4  1893  .  .  .     14.4  1904  .  .  .     16.0 

1883  .      .      .      6.1  1894  .  .  .     12.5  1905  .  .  .     16.7 

1884  ...      9.2  1895  .  .  .     15.3  1906  .  .  .     17.6 

1885  .      .      .     11.7  1896  .  .  .     15.0  1907  .  .  .     17.9 

1886  .      .      .11.5  1897  .  .  .16.0  1908  .  .  .17.0 

1887  .      .      .12.9  1898  .  .  15.8  1909  .  .  .19.3 

1888  .      .      .13.1  1899  .  .  .     15.3  1910  .  .  .     18.4 

1889  .      .      .     13.8  1900  .  .  .     17.0  1911  .  .  .     16.9 

1890  .      .      .     13.5  1901  .  .  .     14.8  1912  .  .  .     17.7 

The  statistical  increase  in  diabetes  in  various  countries  and  cities 
has  been  instructively  tabulated  by  Magnus-Levy.  The  table 
is  so  arranged  that  the  number  of  deaths  for  the  first  date  is 
set  at  100  and  the  relative  number  at  the  later  date  is  shown  by 
the  figures  in  the  right-hand  column. 

TABLE  7. — MAGNUS-LEVY.1 

1.  United  States   ....  1850  100  1880  266 

2.  England 1850  100  1895  310 

3.  Italy 1888  100  1901  176 

4.  Prussia 1870  100  1890       pa.  450 

5.  Berlin 1873  100  1903  940 

6.  Paris ca.  1870  100  1900  520 

A  similar  progression  in  the  frequency  of  diabetes  is  also  seen  in 
the  statistics  of  England  and  Wales: 

TABLE  8. — ENGLAND  AND  WALES.  - 

Deaths  from  Diabetes  per   100,000. 

1851  .  .  .  2.; 

1852  .  .  .2.: 

1853  .  .  .  2.: 

1854  .  .  .  2.- 

1855  .  .  .  2.- 

1856  .  .  .  2.: 

1857  .  .  .  2.; 

1858  .  .  .  2.; 

1859  .  .  .  2.; 

1860  .  .  .  2.1 

1861  .  .  .  2.1 

1862  .  .  .  2.< 

1863  .  .  .  2.; 

1864  .  .  .  3.1 

1865  .  .  .  3.1 

1866  .  .  .  3.5 

1867  .  .  .  3.1 

1868  .  .  .  3.1 

1869  .  .  .  3.- 

1870  .  .  .  3.) 

1871  .  .  .  3..r 

1  Magnus-Levy:  Spez.  Path.  u.  Therap.  inn.    Krank.,    Kraus   u.    Brugsch,    Berlin 
1913,  Bd.  i,  S.  39. 

2  Registrar -General's  Report  of  England  and  Wales. 


1872  .   , 

.   3.3 

1893  . 

.   .   7.0 

1873  .   . 

.   3  .  5 

1894  . 

.   .   6.8 

1874  .   . 

.   3.7 

1895  . 

.   .   7.5 

1875  .   , 

.   3.9 

1896  . 

.   .   7.4 

1876  .   . 

.   3.7 

1897  . 

.   .   7  .  8 

1877  .   . 

.   4.1 

1898  . 

.   .   8.2 

1878  .   . 

.  4.2 

1899  . 

.   .   8.5 

1879  .   . 

.   4.1 

1900  . 

.   .   8.6 

1880  .   . 

.   4.1 

1901   . 

.   .   9.1 

1881  .   , 

.   4.7 

1902  . 

.   .   8.4 

1882  .   . 

.   4.7 

1903  . 

.   .   8.5 

1883 

5  1 

1904 

9  .3 

1884  .   . 

.  5.4 

1905  . 

'.   '.  9.3 

1885 

o  o 

1906 

9  7 

1886  .   , 

.   5  .  9 

1907  . 

.   '  9^7 

1887  .   . 

.   6.2 

1908  . 

.   .  10.3 

1888  .   . 

.   6.2 

1909  . 

.   .  10.4 

1889  .   . 

.   6.0 

1910  . 

.   .  11.0 

1890  .   . 

.   6  .  5 

1911  . 

.   .  10.7 

1891  .   . 

.   6  .  6 

1912   . 

.   .  11.1 

1892  .   . 

.   6.8 

24  DIABETES  MELLITU8 

The  same  upward  tendency  in  the  prevalence  of  diabetes  is  noted 
in  Japan.  This  is  shown  by  Iwai's1  reports  of  admissions  to  the 
lied  Cross  Hospital  and  the  Hospital  of  the  Imperial  Utiversity 
in  Tokyo,  as  exhibited  in  Table  9. 

TABLE  9. — INCIDENCE  OF  DIABETES  IN  TOKYO. 
RED  CROSS  HOSPITAL. 

Per  font,  of 

Oases  of          admissions 
Year.  Admissions.  diabetes.          for  diabetes. 

1891-1S93 1,134  7  0.61 

1S97-1900 1,367  13  0.95 

1901-1903 1,449  17  1.17 

1906-1908 1,006  16  1.59 

HOSPITAL    OF    IMPERIAL    UNIVERSITY,    TOKYO. 

1900-1902 24,424  59  0.24 

1903-1906 39,016  135  0.34 

1907-1910 47,289  207  0.43 

No  accurate  figures  are  available  for  the  total  number  of  diabetic 
patients  in  the  United  States.  Since  approximately  1  death 
out  of  each  75  in  the  United  States  is  due  to  diabetes,  one  might 
be  tempted  to  assume  that  1.3  per  cent,  of  the  living  population 
will  have  the  disease.  Support  for  this  estimate  is  furnished  by 
the  statistics  of  Barringer,2  based  upon  the  frequency  with  which 
sugar  was  found  in  the  urines  of  72,000s  adults  examined  for  life 
insurance  in  New  York  City.  His  method  of  investigation  showed 
that  nearly  2  per  cent.4  of  this  large  group  of  the  adult  population 
in  a  city  had  diabetes.  It  would  be  unjustifiable  to  apply  this 
conclusion  in  this  form  to  the  entire  population,  because  diabetes 
is  comparatively  rare  in  the  early  part  of  life  but  increases  in 
frequency  as  age  advances,  and  Barringer's  data  relate  to  adults. 
The  incidence  of  diabetes  might  be  far  below  1  in  75  in  the  first 
and  second  decades  of  life  and  then  increase  to  1  in  50  or  even  1  in 
40  of  the  population  from  the  sixth  decade  onward.  Today  our 
information  rests  upon  hypothetical  grounds,  but  within  a  few 
years  far  more  satisfactory  information  will  be  available.  For  the 
present  it  is  probably  underestimating  the  number  of  diabetics  in 
the  country  to  state  that  approximately  1  in  75  of  all  individuals 
cither  have  the  disease  or  will  develop  it.  By  this  method  of 
reckoning  there  arc  over  1,000,000  potential  diabetics  in  the 
country. 

Should  an  estimate  be  based  upon  the  total  deaths  from  diabetes 


1  Iwai:    Lc  DiulxMc   Sucre   clu>z  Irs   Japouais.       Tokyo.       Translated   by  L 
Paris;  Masson  et,  ( 'ompanie,  IvlitiMii 
-  Harrinucr:  Arch.  Int.  Mcd..   1'JD!) 
:l  Actually  71,712!).  *  l.S'Jo  per  rent. 


STATISTICS  RELATING   TO  DIABETES  25 

annually,  a  different  result  would  be  reached.  Thus,  in  the  regis- 
tration area  of  the  United  States  for  J915  the  deaths  from  diabetes 
were,  in  round  numbers,  12,000,  and  on  this  basis  for  the  whole 
country  18,000.  Allowing  a  duration  of  five  and  half  years  for  each- 
case,  the  total  number  of  diabetics  would  be  100,000.  Personally 
I  believe  the  number  of  cases  of  diabetes  in  the  United  States  is 
much  nearer  to  1,000,000  than  to  100,000. 

2.  The  Explanation  of  the  Statistical  Increase  in  Diabetes.— 
(a)  Greater  Accuracy  of  Vital  Statistics. — The  increased  accuracy  of 
vital  statistics  in  recent  years  undoubtedly  explains,  to  a  great 
extent,  the  apparent  increase  in  diabetes.  It  is  evident  from  the 
study  of  the  incidence  of  diabetes  in  different  localities  that  the  rate 
is  highest  where  one  would  expect  the  statistics  to  be  most  trust- 
worthy. 

(6)  More  Frequent  Urinary  Examinations.— The  chief  cause  for  the 
improvement  in  the  vital  statistics  upon  diabetes  lies  in  the  increased 
frequency  of  routine  urinary  examinations.  Urinary  examinations 
are  comparatively  recent.  This  is  shown  by  the  records  of  a  case  of 
diabetes  at  the  Massachusetts  General  Hospital  for  the  year  1866, 
where  the  words  ''urine  tasted  sweet"  may  be  seen  in  the  hand- 
writing of  a  house  pupil,  later  a  professor  in  the  Harvard  Medical 
School,  and  now  still  vigorous.  The  frequency  of  diabetes  in  a 
community  may  be  the  index  of  the  intelligence  of  its  physicians. 

(c)  General  Increase  in  Duration  of  Life. — Another  cause  for  the 
apparent  increase  in  the  frequency  of  diabetes  is  connected  with 
the  general  increase  in  the  duration  of  life  throughout  the  world. 
This  is  of  more  importance  in  studying  the  incidence  of  diabetes 
than  it  would  be  with  the  infectious  diseases.  The  infectious 
diseases  are  common  to  the  early  years  of  life,  and  consequently 
prolongation  of  life  would  affect  their  incidence  comparatively 
little;  but  with  diabetes  quite  the  opposite  is  the  case.  I  am 
under  the  impression  that  just  as  in  cancer  so  it  is  with  diabetes, 
the  longer  a  person  lives  the  more  liable  he  is  to  the  disease.  This 
increase  in  the  duration  of  life  is  really  considerable.  The  approx- 
imate age  at  death  from  all  causes  in  the  registration  area  of  the 
Unites  States  in  18(50  and  for  following  decades  is  shown  in  the 
subjoined  table  : 

TABLE  10. — THK  AVERAGE  AGE  AT  DEATH  ix  THE  REGISTRATION  AREA 
OF  THE  UNITED  STATES. 

1800 22 . 7  years 

1870 25.2' 

1880 2t>.9 

1890 31.1 

1900 35.2 

1910 38.7 

1915  42.2 


20  DIABETES  MELLITUS 

rrhis  increase  in  the  average  duration  of  life  is  also  evident  from 
German   mortality   tables: 

TAHLK   11. — 'I'm;  AVEKACH;   KXPKCTATION'  OF   LIFK   AT  BIRTH  ix  (!KKMA\Y.  ' 

Men.  Woinon. 

1S71-1SSO 3.r>.t>  38.4 

1SS1-1SW) 37.2  40.2 

1891-1000 40.1)  44.0 

1901 -19 10  .                                                                          44.8  48.3 


In  Sweden  the  average  length  of  life  is  said  to  be  about  ten 
years  longer  than  in  Germany. 

In  quite  a  different  manner  this  question  has  been  approached 
by  the  Department  of  Health  of  New  York.  According  to  a  table 
recently  published,  the  life  table  based  upon  mortality  during  the 
years  1909  to  1911  inclusive  is  compared  with  a  similar  table  for 
the  years  1879  to  1881  inclusive.  This  shows  the  expectancy  of 
life  at  stated  ages  for  males  and  females.  It  appears  that  children 
under  five  years  of  age  in  the  former  period  had  an  expectancy  of 
forty-one  years  and  that  today  a  child  of  that  age  may  look  forward 
to  an  expectancy  of  fifty-two  years,  or  an  increase  of  eleven  years 
of  life.  The  life  of  a  child  of  ten  years  has  been  prolonged  more  than 
five  years.  An  individual  from  twenty-five  to  thirty  years  of  age 
had  an  expectancy  thirty  years  ago  of  32.0  years,  while  now  his 
expectancy  is  34.3  years,  an  increase  of  1 .7  years.  On  the  other  hand, 
individuals  between  forty  and  forty-five  years  old  had  an  expec- 
tancy of  23.9  years  in  the  earlier  period,  but  at  the  present  time 
23.4  years,  a  decrease  in  the  expectancy  of  six  months.  Dublin's2 
explanation  of  this  phenomena  is  reassuring  to  native  Americans, 
for  he  ascribes  it  to  the  influx  of  approximately  22, ()()(),( )()()  immi- 
grants in  the  last  fifteen  years.  Almost  invariably  the  expectation 
of  life  in  the  countries  from  which  these  came  was  below  our  own. 
lie  has  also  demonstrated  for  the  State  of  New  York  that  the 
mortality  rates  for  native  born  of  native  parentage  are  far  more 
favorable  than  for  the  native  born  of  foreign  or  mixed  parentage  or 
for  the  foreign  born. 

(d)  Life  Insurance  Statistics.—  The  statistics  of  insurance  companies 
are  direct  evidence  against  any  such  rapid  increase  in  the  frequency 
of  diabetes.  This  is  shown  by  the  records  of  two  of  the  large 
insurance'  companies  in  the  United  States  in  the  number  of  rejections 
for  sugar  for  successive  years.  (See  Table  12.) 

'See  Stalislik  <los  Dentx-lien   Hcichs,  15an<l  rcxlvi,  pp.   14  and  Hi. 

2  Dublin:    Lor.  cit.,  p.  21;  also  Amor.  Kconomir  Review,  1910,  vi,  Xo    .'?,  p.  ~>'2'1. 


STATISTICS  RELATING  TO  DIABETES  27 

TABLE  12. — REJECTIONS  ON  ACCOUNT  OF  CLYCOSURIA  BY  Two  LARCIE 

INSURANCE  COMPANIES. 

COMPANY  A. 

Applications 
declined  on 

Applications  account  of  Hate  per 

Year.  received.  suj;ar.  1000. 

i9i;? 501 

1914 492 

1915 574 

COMPANY    B. 

1910 10,596  50  5.29 

1911 11,709  77  6.58 

1912 13,851  80  0.21 

1913 13,805  80  5.79 

1914 13,748  73  5.31 

1915 15,311  90  7.27 

Unfortunately  I  have  been  unable'  to  secure  data  from  other 
of  the  larger  insurance  companies  which  would  show  whether  the 
percentage  of  rejection  on  account  of  sugar  being  found  in  the  urine 
had  increased  during  the  last  thirty  years.  So  far  as  I  can  learn 
from  correspondence  and  conversation  with  those  in  insurance 
companies  who  are  in  a  position  to  know,  the  percentage  of  rejec- 
tions has  remained  constant  for  many  years. 

(c)  Frequency  by  Decades  at  which  Onset  Occurs  Now  and  Formerly. — 
An  increase  in  the  incidence  of  diabetes  should  also  be  manifested  in 
each  decade  of  life  if  such  an  increase  was  actual.  Von  Noorden  has 
summarized  such  statistics,  and  at  first  sight  they  favor  the  view  that 
the  increase  in  diabetes  is  actual  and  not  apparent.  (See  Table  13.) 
It  will  be  seen  that  successive  writers  at  successive  periods  report 
a  similar  distribution  of  their  cases  among  the  different  decades. 
This  conclusion  is  not  justified,  because  most  of  the  writers  quoted, 
although  living  at  somewhat  different  periods,  nevertheless  lived 
before  the  time  when  urinary  examinations  were  really  part  of  the 
general  routine.  Von  Xoorden's  statistics  represent  a  later  era, 
and  it  is  noticeable  that  lie  had  at  least  50  per  cent,  more  cases 
in  the  first  decade  of  life  than  earlier  writers.  My  own  statistics 
being  still  more  recent  bring  out  this  point  even  more  strongly, 
for  they  show  three  times  as  many  as  von  Xoorden's1  1.43  per  cent. 
— namely,  5S  cases  or  4.9  per  cent,  in  contrast  to  1  per  cent,  or  less 
which  writers  prior  to  von  Xoorden  report.  Of  GOX  cases  of  dia- 
betes recently  reported  by  Iwai,2  in  Japan,  not  a  single  case  was 
encountered  in  the  first  decade  of  life!  Writing  even  as  late  as  in 
1015,  De  Lange  and  Schippers3  mention  only  500  to  GOO  cases  of 
diabetes  in  children  being  upon  record.  The  point  may  be  raised 
that  on  account  of  my  interest  in  diabetes  and  the  feeling  of 

1  See  von  Xoorden:    Die  Zuckerkrankheit,  Berlin,  1912,  p.  59. 

-  Iwai:    Lor.  cit.,  p.  i>4. 

3  De  L:inge  and  Schippers:  Jour.  Am.  Mod.  Assn.,  1915,  Ixv,  p.  1150. 


28  DIAKETES  MELLITUS 

the  hopelessness  of  the  disease  in  children  a  proportionately  larger 
number  of  vomit;  than  of  older  diabetics  may  have  come  to  me. 
This  is  undoubtedly  true,  but  this  argument  applies  to  the  other 
writers  cited  with  even  more  force. 

OF  ONSF.T  OF  DIABF/TFS  BY   DKCADKS. 


4.  . 

5. 

0, 

7 

g. 

Per  cent. 

18.0 

25  .  0 

20.0 

1  1.0 

1.0 

" 

10.0 

24.0 

30.0 

10.0 

0  .  5 

" 

11.2 

23  .  1 

39.5 

IS    1 

3.4 

" 

17.3 

22  .  3 

32.0 

10.0 

3.3 

" 

1(1.4 

24  .  9 

30.7 

13  .4 

2  5(1 

" 

17.2 

3H.O 

20.8 

9.2 

0   1 

" 

10.0 

21.0 

17.7 

4   04 

0.43 

mild. 

!t  .  57 

12.57 

11.0 

2    14 

severe  and  mo< 

severe. 

13.8 

24.2 

24  .  2 

11.9 

2.S 

Joslin  . 


The  dates  of  publications  of  the  authors  cited  are  given  in  the 
foot-notes  on  this  page. 

This  increase  in  the  percentage  of  cases  in  the  first  decade  as 
compared  with  a  generation  ago  therefore  speaks  in  favor  of  the 
better  diagnostic  methods  of  today  rather  than  of  actual  increase 
in  the  frequency  of  the  disease. 

(/)  The  Importance  of  Recognition  of  the  Extent  of  Diabetes  in  the 
Community  and  its  Influence  upon  Treatment. — The  recognition  of 
the  large  number  of  diabetic  individuals  living  in  the  United  States 
is  important.  It  determines  the  character  of  the  treatment.  The 
number  of  cases  is  so  great  that  it  at  once  becomes  evident  that 
their  care  must  rest  in  the  hands  of  the  general  practitioner.  It  is 
ridiculous  to  expect  that  the  treatment  of  diabetics  should  be 
under  the  supervision  of  a  specialist,  neither  can  they  all  undergo 
hospital  treatment.  It  is  plain  that  a  program  of  education  not 
only  of  the  diabetic  patients  themselves  but  the  population  as  a 
whole  must  he  instituted  along  similar  lines  to  that  which  has 
been  adopted  in  the  treatment  of  tuberculosis.  Hut  first  of  all  this 
program  must  begin  with  the  doctor.  The  campaign  against 
tuberculosis  has  given  the  community  fresh  air.  A  campaign  for 
the  prevention  and  treatment  of  diabetes  should  give  the  com- 
munity a  knowledge  of  diet  and  the  importance  of  physical  exercise. 
The  gain  to  the  community  from  the  dissemination  of  such  knowl- 
edge will  almost  oil'set  the  harm  caused  by  diabetes.  In  this 
campaign  I  would  especially  emphasize  the  importance  of  the 
education  of  the  general  practitioner  in  dietetics.  To  treat  the 

1  Freriehs:   T'eber  don  Diabofes,  Berlin,  1SS4. 

"Soe-icn:    Der  Diabetes  Melims,  Merlin,  I  Aufll.,  1S70,  III  Aufl.,  IS'.):}. 
3Cirube:   Diiitetisehe  BchandlunK  tier  Zurkerkruukheit,  Morm.  is'.ls. 
4Schinit/:    Merl.  klin.  \Vorh.,  1S7:{,  xviii,  S.  KS;  also  Merlin,  1S91,  S.  :57:5. 
:'Pavy:  On  Diabetes,  London,  IMi'.l;  Different  iat  ion  in  Diabetes,  London,  1900. 
fi  Ki'ilz:   Klinisrhe  Krfahnmnon  i'lber  Diabetes  Melitus,  Herausg.  von   Kunipf,  Jena, 
1899. 

7  Von  Xoorden:   Lor.  cit.,  Berlin,  1912. 


TREATMENT  OF  DIABETES  MELLITUS  29 

100,000  to  1,000,000  diabetic  patients  in  the  United  States  there 
were  in  191()  145,241  physicians,  so  that  a  physician  will  rarely 
see  over  5  to  10  diabetics  a  year.  Under  normal  circumstances  he 
cannot  give  much  time  to  the  study  of  so  few  patients.  In  other 
words,  suggestions  for  treatment  must  be  of  the  simplest  character. 
The  greatest  mistake  that  can  happen  in  the  treatment  of  diabetes 
today  would  be  to  advocate  dietetic  methods  which  would  involve 
complicated  analyses  of  urine  and  blood.  The  greatest  advantage 
of  the  fasting  treatment  introduced  by  Dr.  Allen  lies  in  its  simplicity 
and  in  the  removal  of  the  need  for  quantitative  urinary  examinations. 

C.     THE  IMPROVEMENT  IN  THE  TREATMENT  OF  DIABETES 

MELLITUS. 

For  the  successful  treatment  of  a  chronic  disease  it  is  essential 
that  the  physician  be  convinced  that  his  methods  of  treatment  are 
improving.  This  I  thoroughly  believe  to  be  the  case  in  diabetes 
mellitus.  It  is  freely  granted  that  occasionally  one  sees  diabetic 
patients  in  middle  life  who  claim  that  they  have  disregarded  treat- 
ment and  yet  have  maintained  health  and  strength,  but  investiga- 
tion usually  shows  (1)  that  the  type  has  been  mild;  (2)  that  the 
individual  is  unusually  intelligent,  and  (3)  although  he  disclaims  it, 
that  he  has  really  adopted  a  mode  of  life  and  diet  essentially  con- 
sistent with  sound  treatment.  Case  Xo.  354  is  one  in  point.  While 
at  the  head  of  a  large  insurance  business  at  the  age  of  fifty,  sugar 
was  found  in  his  urine.  Although  he  claimed  to  have  disregarded 
routine  treatment,  he  really  lived  on  a  diet  containing  little  sugar 
and  much  fat.  Sixteen  years  later  sugar  disappeared  permanently 
from  the  urine  and  he  was  able  to  eat  sweets  without  harm.  Al- 
bumin and  casts  then  appeared,  the  blood-pressure  rose  to  ISO  mm., 
and  the  patient  died  at  the  age  of  seventy-one  years. 

1.  Indirect  Improvement. — Various  factors  have  contributed 
indirectly  to  an  improvement  in  treatment  such  as  an  early 
diagnosis,  a  better  understanding  of  the  diet  and  the  disease,  and 
the  better  treatment  of  complications. 

(a)  Early  Diagnosis. — Success  in  the  treatment  of  diabetes,  as 
well  as  of  consumption,  depends  upon  an  early  diagnosis,  and  all 
will  agree  we  are  in  a  much  more  favorable  position  to  make  early 
diagnoses  now  than  were  the  physicians  of  a  former  generation. 

1.  liuntine  Urinary  Examinations. — The  favorable  outcome  in  a 
considerable  percentage  of  the  cases  can  be  attributed  to  the  early 
detection  of  the  disease.  Xaimyn  especially  urges  the  importance 
and  good  results  of  early  treatment.  A  notable  percentage  of  the 
total  number  of  my  diabetic  patients  were  apprised  of  their  disease, 
not  so  much  because  of  their  symptoms,  but  because  of  routine 
urinary  examinations.  It  appeared,  therefore,  of  interest  to  examine 


;]()  DIABETES  MELUTUS 

into  the  duration  of  life  of  the  living  and  fatal  cases  of  this  group, 
because  of  the  possibility  that  the  duration  of  the  disease  among 
these  patients  might  be  longer  or  shorter  than  the  average  of  all 
the  patients,  With  this  end  in  view  I  constructed  Table  Y.V  in  my 
first  edition,  but  a  more  careful  attention  to  this  point  during  this 
last  year  has  led  me  to  discard  it,  because  of  the  difficulty  of  deciding 
whom  1  should  include  in  this  class.  The  issue,  however,  is  ade- 
quately met  in  a  statistical  way  in  the  scries  of  cases  which  com- 
prises those  diabetics  who  became  cognizant  of  their  disease  through 
examinations  for  life  insurance  (see  p.  IOC)),  When  a  routine 
urinary  examination  is  neglected,  the  damage  done  to  the  patient 
is  considerable,  and  to  the  physician's  reputation  is  extreme.  The 
physician  is  never  forgiven! 

The  time  is  probably  not  far  distant,  if  not  already  here,  when 
the  question  will  be  asked  of  the  diabetic:  "  How  long  did  the  disease 
exist  before  it  was  discovered?"  and  "Who  was  your  physician?'' 
We  are  familiar  with  the  same  questions  in  tuberculosis. 

2.  Examinations  for  .Life  Insurance.—  An  early  recognition  of  the 
disease  is  promoted  by  examinations  for  life  insurance. 

The  percentage  of  the  population  in  the  I'nited  States  which  is 
undergoing  such  examination  is  steadily  increasing.  This  is  shown 
in  Table  14,  which  is  based  upon  the  number  of  policies,  not  includ- 
ing industrial  insurance,  in  force  at  the  end  of  the  years  indicated 
as  shown  by  the  Spectator  Company's  Year-book  for  li)10. 

TABLE   14. — LIFK   I \sru.\\rK   POI.ICIK.--   ISSTHD  i\  THE   UNITED  STATES. 

IVr  cent,  of  populn- 
Popuhition.  tion  buying  policies. 

f>o,if>r>,7x:5  "  i 

(12,947,714  2 

7"),!)'.M..")7r)  4 

<n,972.2<>»)  7 

100. :;<><>.:;  ix  (Vst.)  S 

The  above  figures  include  policies  in  force  in  all  companies  in 
the  country.  The  number  of  individuals  carrying  one  or  more 
extra  policies  reduces  the  total  number  insured,  but  this  is  more 
than  offset  by  those'  examined  for  insurance,  and  then  refused. 

Seventy-six  cases  of  my  series  discovered  the  disease  as  a  result 
of  an  examination  for  life  insurance.  All  of  these  cases  were  men. 
In  other  words,  life  insurance  examinations  were  responsible  for 
the  detection  of  diabetes  in  1  1  per  cent,  of  my  male  cases  above  the 
age  of  ten  years. 

It  is  acknowledged  that  in  many  the  disease  was  undoubtedly 
mild,  but  its  detection  afforded  an  unusually  early  opportunity 
for  treatment.  The  favorable  outcome  of  these  cases  is  encouraging. 
(See  Table  MO,  p.  107.) 


Year. 
1XSO     .      .      . 
IX'.H)     .      .      . 

Total. 
.      .         f.OX.IiXl 
.      .      l,27l>,  107 

1  '.)()()     .      .      . 

niio   .     .     . 
i'.iir>   . 

.     .    :*.()7l.2f>:i 
.      .     0,040,017 
S.284.281 

TREATMENT   OF   1)1  ABET  E8   MELLITUH  .'51 

(/;)  Knowledge  of  Diet  More  General. — An  accurate  knowledge  of 
the  diet  is  responsible  for  a  large  share  of  the  improvement.  For 
this  we  are  indebted — first  to  the  publication  by  the  United  States 
Government  of  Bulletin  No.  28, l  and  especially  to  the  vigorous 
campaign  conducted  under  the  auspicies  of  Professor  Street  at  the 
Connecticut  Agricultural  Experiment  Station  in  bringing  to  com- 
mon knowledge  the  carbohydrate  content  of  so-called  diabetic 
foods.  Twenty-five  years  ago  a  knowledge  of  the  carbohydrate 
content  of  the  food  of  an  individual  was  almost  negligible.  One  is 
free  in  making  this  statement  because  even  today  relatively  few 
physicians  can  reckon  up  the  carbohydrate  in  the  diet  of  their 
patients.  For  this  lack  of  instruction  in  diet  medical  teaching  is 
largely  responsible.  I  know  that  as  hospital  assistants  our  estima- 
tion of  the  carbohydrate  which  our  patients  took  began  and  ended 
with  the  statement  that  most  gluten  breads  were  fraudulent. 

It  is  not  at  all  strange  that  physicians  in  general  practice  are 
unacquainted  with  carbohydrate  food  values,  because  it  is  only 
within  a  decade2  that  such  information  has  begun  to  appear  in  the 
literature  and  a  much  longer  period  is  required  for  it  to  become 
widely  circulated. 

(c)  The  Disease  is  Better  Understood. — It  is  no  longer  considered 
almost  miraculous  for  a  patient  to  void  a  urine  with  11  per  cent, 
of  sugar  upon  one  day  and  a  few  days  later  to  become  sugar-free. 
It  is  recognized  that  a  blood  sugar  of  0.4  per  cent,  falls  slowly  and 
that  with  renal  complications  may  not  reach  normal,  and  that  under 
these  circumstances  sugar  may  persist  for  days  or  even  weeks  in  the 
urine.  Successes  with  bizarre  methods  of  treatment,  such  as  an 
exclusive  buttermilk  diet,  are  now  explained  by  the  accompanying 
undernutrition  which  they  entailed. 

The  merits  of  a  new  method  of  treatment  are  more  quickly 
determined  today  than  a  generation  ago,  and  this  contributes  to 
better  treatment.  The  number  of  new  remedies  exploited  upon 
the  profession  and  upon  the  laity  is  gratifyingly  growing  less. 
Physicians  realize  better  than  formerly  that  the  value  of  any 
remedy  in  the  disease  must  depend  upon  its  power  to  increase 
tolerance  for  carbohydrates,  and  as  no  remedy  so  far  has  been 
shown  to  be  capable  of  bringing  this  about,  confidence  in  drugs  is 
less  frequently  secured.  This  means  much,  because  formerly  valu- 
able time  was  lost  and  the  strength  of  many  patients  exhausted  in 
useless  therapeutic  procedures. 

(<7)  The  Better  Treatment  of  Complications. — Complications  are  less 
numerous  at  the  present  time,  and  when  they  do  occur  are  more 
intelligently  treated.  The  older  authorities  believed  tuberculosis  to 

1  Chemical  Composition  of  American  Food  Materials,  Bulletin  Xo.  2s,  U.  S. 
Department,  of  Agriculture.  This  can  he  obtained  by  sending  10  cents  in  coin  to 
Superintendent  of  Documents,  Washington,  D.  C. 

-  Bulletin  No.  28  first  appeared  in  1906. 


32  DIABETES   MELLITUS 

be  about  the  worst  foe  of  the  diabetic  patient,  and  they  were  prob- 
ably  right  in  their  conviction.  Today  preventive  medicine  removes 
tliis  danger  to  a  large  extent.  Similarly,  septic  processes  are  avoided. 

Frerichs1  found  in  55  autopsies  upon  diabetic  patients  tubercu- 
losis to  be  present  twenty-five  times.  In  his  private  practice  at 
Frankfort,  von  Noorden-  noted  tuberculosis  in  5.5  per  cent.,  but  in 
his  hospital  practice  15.1  per  cent.  In  Vienna  the  percentage  rose 
to  27.  Among  my  cases  only  2.9  per  cent,  were  known  to  have 
open  tuberculosis,  and  among  241  new  cases  seen  during  the  year 
ending  December  1,  1910,  tuberculosis  was  demonstrated  to  be 
active  in  3,  or  1.2  per  cent. 

2.  Direct  Improvement  Shown  by  Statistics. — Positive  proof  of 
improvement  in  treatment  would  be  afforded  if  it  could  be  shown 
that  the  average  duration  of  life  of  diabetic  patients  was  greater 
today  than  twenty  years  ago.     This  I   unquestionably  believe  to 
be  true.    In  order  to  secure  information  upon  this  point  9X  per  cent, 
of  945  cases  of  diabetes  seen  by  me  in  private  practice  from  1X93 
to  November  IS,  1915,  were  traced.    Of  these  922  cases  it  was  learned 
that  420  had  died.     One  year  later,   December    1,   1910,  another 
compilation  was  made  and  the  condition  of  97.4  per  cent,  of  the 
11X7  cases  seen  since  1X94  was  ascertained.     The  fatal  cases  now 
number  5 Hi.     The  second  series  of  data,  therefore,  will  serve  for 
comparison  with  the  former,  and  if  the  treatment  of  diabetes  is 
improving,  some  indication  of  it  should  become  apparent.     Both 
series  of  cases  have  been  grouped  in  decades  according  to  the  onset 
of  the  disease.     The  actual  onset  of  the  diabetes  in  each  case  was 
sought  with  care  and  for  a  large  number  of  the  cases  the  records 
not  only  show  the  probable  onset,  but  the  date  on  which  the  diag- 
nosis of  the  disease  was  proven  by  urinary  examination.     Nearly  all 
the  histories  have  been  personally  taken  by  me,  and  my  records  there- 
fore are  uniform.    Before  recording  my  own  statistics  reference  should 
be  made  to  the  data  of  Naunyn  and  von  Noordcn  and  the  statistics 
of  the  City  of  Boston  and  of  the  Massachusetts  General  Hospital. 
(a)  Massachusetts   General  Hospital,   1824-1898,  1898-1913,  1913- 
1916.     These   data    are   of    especial    value    because   they   show   the 
duration  of  life  of  diabetic  patients  for  three1  epochs.     The  first 
period  includes  all  eases  from  the  beginning  of  the  records  of  the 
hospital   in    1>>24   1o    1X9X  and   the   second   from    1X9X  to    19K5-    a 
period  which  is  sufficiently  remote  to  exclude  the  results  of  modern 
treatment.     The  third    period    (191:5    1910)   represents  one  year  of 
the  older   methods  of   treatment,   the   first   year   of   modern   treat- 
ment  (a   transitional  year)  and  one  complete  year  under  the  con 
ditions  of  the  treatment  today.      For  the  first   period  I   personally 
examined  each  history  upon  the  medic;!!  side  of  the  hospital,  for  in 
those  early  years  there  was  no  index,  and  collected  the  diabetic  cases 
and  recorded  whether  the  information  as  to  duration  was  trust- 

1  Freriohs  :  ( 'iiivl  by  Xaunyii,  lor.  cit ..,  p.  2  I'.).  -  Von  Xoorden  :  Lor.  fit.,  p.  196. 


TREATMENT  OF  DIABETES  MELLITUS  33 

worthy.  These  data  with  others  were  published  conjointly  with 
R.  H.  Fitz.1  The  statisties  for  the  years  LSUS  to  1913  and  1913-1916 
were  collected,  under  my  direction,  by  my  secretary,  Miss  Helen 
Leonard,  and  the  duration  of  each  case  verified  by  my  former 
assistant,  Dr.  F.  Gorham  Brigham.  For  the  privilege  of  inserting 
these  data,  which  are  of  value  as  a  measure  of  the  improvement 
in  treatment,  I  am  deeply  indebted  to  the  Superintendent  and 
Staff  of  the  Massachusetts  General  Hospital. 

TABLE  15. — THE  DURATION  OF  LIFE  OF  CASES  OF  DIABETES  WHO  DIED  AT 
THE  MASSACHUSETTS  GENERAL  HOSPITAL  BETWEEN  THE  YEARS  1824-1898. 

Duration,  years.  Number  of  cases.  Percent. 

0-1 27  67.5 

1-2 7  17.5 

2-3 3  7.5 

3-4 1  2.5 

4-5 0 

5-6 1  2.-5 

6-7 1  2.5 

40 

Of  the  total  number  of  172  diabetic  patients  treated  during  these 
seventy-four  years,  47  or  27  per  cent,  died  within  the  hospital 
walls.  The  duration  of  7  of  the  fatal  cases  could  not  be  determined. 

TABLE  If). — THE  DURATION  OF  LIFE  OF  CASES  OF  DIABETES  WHO  DIED  AT 

THE  MASSACHUSETTS  GENERAL  HOSPITAL  BETWEEN  THE  YEARS 

1898  TO  NOVEMBER,  1913. 

Duration,  years.  Number  of  cases.  Per  cent. 

40.6 

18.8 
8.7 
8.7 
2.9 
7.2 
1.4 
2.8 
\A 
1.4 
1.4 
2.9 
1.4 


Total 79 

Of  the  total  number  of  280  diabetic  patients  treated  during  these 
years  79  or  28  per  cent.  died.  Whereas  the  percentage  of  patients 
who  died  in  the  hospital  during  the  two  periods  was  the  same,  it  is 
evident  that  the  duration  of  life  of  the  patients  was  distinctly  greater 
in  the  second  period.  The  most  striking  feature,  however,  is  the 
lessened  fall  in  mortality  during  the  first  year  of  07.5  per  cent,  to 
40.0  per  cent.  The  statistics  lend  weight  to  the  inference  that  the 

1  Fitz  and  Joslin:  Diabetes  Mellitus  at  the  Massachusetts  General  Hospital, 
1824-1898,  Jour.  Am.  Mcd.  Assn.,  189S,  cxxxix,  p.  70. 

3 


0-1     

.     28 

1-2     

.      13 

2-3    

6 

3-4    

6 

4-5     

2 

5-  6 

6-  7     .            

1 

7-8    

2 

9-10     

1 

10-11     

1 

15-16     

1 

16-17     

2 

20-21     

1 

G9 

Unknown  because  of  lack  of  past  history  . 

.      10 

34  DIAHKTKS   MKLLiri'S 

treatment  of  the  disease  as  51  whole  in  the  community  had  improved, 
but  that  the  intensive  treatment  of  such  cases  as  came  to  the- hospital 
remained  stationary. 

TAHLE  17. — THE   DURATION  OF  LIKE  OK  TWENTY-SEVEN  CASES  OF  DIABETES 

WHO  DIED  AT  THE  MASSACHUSETTS  (!ENERAL  HOSPITAL  BETWEEN 

NOVEMBER,   1913,  AND  JANUARY,   1917. 

Duration,  years.  Number  of  cases.  Per  cent. 

0-  1 10  47.0 

1-2 1  4.8 

2-3 2  9.5 

4-  5 3  14.3 

5-  0  ...                   2  9.5 

0-7 1  4.8 

10-11 1  4.8 

15-10 1  4.8 

Unknown' because  of  lack  of  past  history  .      .       0 

Total 27 

During  this  period  243  cases  of  diabetes  were  treated  at  the 
hospital  and  the  number  of  deaths  was  27,  or  11  }>cr  rent. 

Such  a  reduction  in  mortality  is  gratifying  to  all,  speaks,  well 
for  the  care  the  patients  received  in  the  hospital,  and  is  reliable 
evidence  of  the  improvement  in  treatment  of  the  disease. 

(/>)  City  of  Boston. — The  duration  of  life  of  the  fatal  cases  of  dia  betes 
occurring  in  Boston  for  the  period  1895-1913  and  for  1915  are  given 
in  the  subjoined  table. 

TABLE  18. — DURATION  OF  LIFE  OF  1057  FATAL  CASES  OF  DIABETES  IN  BOSTON 
DURING   1895-1913  AND  IN   1915. 

1S05- 1013.  i  1015. 

Number  of  Number  of 

Per  cent.  eases.  Per  cent. 

32 . 7  32  27 . 3 
21.9                        10  13.0 

10.8  18  15.3 
5.9                          5  4.2 

8  0.8 

14  11.9 

2  1.7 

3.2  3  2.5 

0 . 8  3  2 . 5 

0 .3  1  0.8 

0 .4  4  3.4 

0.8  1  0.8 

0.4  3  2.5 

1.8  2  1.7 

0 .4  2  1.7 

0.3  1  O.s 

0.8  2  l.C» 


20 

51 

4 


195 

ton  Medical  ami  Surgical  .Journal,  I'.llii,  clxxv,  p    54. 


Duration,  years. 

cases. 

0-   1 

309 

1-  2     .      . 

.      .      .      207 

2-  3 

102 

3-  4 

50 

4-  5 

71 

5-  C)     .      . 

.      .      .        20 

0-  7     .      . 

.      .      .        24 

7-  8 

30 

8-  9     .      . 

.       .      .          8 

9-10     .      . 

.      .      .        59 

10-11     .      . 

.      .      .          4 

11    12     .      . 

8 

12    13     .       . 

.      .      .          4 

14    15     .       . 

.      .      .        17 

15-10     .      . 

.      .      .          4 

17-lsO  .      . 

.      .      .          3 

20-3       .      . 

8 

940 

Duration      loi 

i(i,      but 

uncertain 

.       .       .      207 

I'liknown    . 

.      507 

Diabetic  jianjz 

:n-ne       .        50 

Total        . 

.    1704 

1  Morrison: 

HoMoii  Medica 

TREATMENT  OF  DIABETES  MELL1TUS  35 

Here  again  a  decrease  in  the  mortality  during  the  first  year  of 
the  disease  is  manifest  in  the  later  year. 

(r)  Naunyn. — In  a  separate  group  should  be  placed  the  statistics 
giving  the  duration  of  life  of  00  of  Xannyn's  severe  cases.  These 
represent  a  special  type  and  should  be  kept  distinct  from  the 
tables  which  precede  and  follow. 

TABLE  19. — THE  DURATION-  OF  LIFE  IN  '"PURE"  AND  '"ORGANIC"  DIABETES 

(XAUNYN,   1906).1 

Duration,  Number  of  cases.  Number  of  cases. 

years.  "Pun1."  Per  cent.  "Organic."  Per  cent. 

0-1 22  33.3  20  28.2 

1-2 19  28.8  15  21.1 

2-3 16  24.2  7  9.8 

3-4 6  9.1  7  9.8 

4-5 .  .  5  7.0 

5-6 1                     1.5  5  7.0 

6-8 2  3.0  4  5.6 

8-10 ..  1  1.4 

over  10 7  9.8 

In  Xaunyn's  statistics,  however,  the  duration  is  based  upon  the 
period  at  which  the  patient  left  his  observation,  but  he  states 
that  none  of  the  cases  could  have  lived  many  months  after  this 
time. 

(r/)  Von  Noorden. — Von  Noorden,2  writing  in  1912,  says  that  dia- 
betes in  children  under  ten  years  of  age  seldom  lasts  more  than  for 
one  and  a  half  or  two  years;  in  the  second  decade  it  seldom  exceeds 
two  to  four  years;  in  the  third  decade  four  to  six  years,  occasionally 
even  ten  years,  and  sometimes  longer.  People  who  acquire  the 
disease  after  the  thirtieth  year  have  a  considerably  greater  length  of 
life,  and  with  favorable  conditions  the  disease  may  last  from  ten 
to  fifteen  years,  or  even  longer.  The  first  half  of  the  fifth  decade, 
however,  is  a  more  critical  period,  but  when  this  corner  is  passed 
the  tendency  of  the  disease  is  to  remain  mild  provided  doctor  and 
patient  have  not  themselves  to  blame.  Such  patients  may  live 
fifteen,  twenty  or  even  thirty  years.  Still,  a  length  of  life  of  more 
than  twenty  years  belongs  to  the  exception. 

(<?)  Author's  Data. —  (1)  Arranged  According  to  Periods  u-hen  First 
Observed,  Irrespective  of  Previous  Duration. — rlhe  date  of  onset  of 
diabetes  is  often  uncertain.  For  this  reason  in  the  first  of  the 
tables  dealing  with  my  own  cases,  the  patients  are  grouped  accord- 
ing to  the  time  they  first  consulted  me  and  wholly  irrespective  of 
the  previous  duration  of  the  disease.  (See  Table  20.) 

The  table  shows  the  results  of  the  inventories  of  my  cases  on 
December  1,  1915  and  on  December  1,  1910. 

v  Naunyn:  Loc.  cit,  p.  370.  2  Yon  Noorden:  Loc.  eit.,  p.  247. 


Period  first 

Total  cases 

Aliv 

O. 

observed. 

traced. 

No. 

Per  cent. 

1893-1900 

.     17 

1 

6 

1901-1905 

.      88 

17 

19 

1900-1910     , 

.   205 

96 

36 

1911-1915     . 

.    552 

379 

09 

1915-1910    . 

3(3  DIABETES  MELLITUS 

TABLE  20. — VITAL  STATISTICS  OF  DIABETIC  PATIENTS  ARRANGED  ACCORDING 

TO  PERIODS  WIIKM  FIRST  OBSERVED,  IRRESPECTIVE  OF 

PREVIOUS  DURATION. 

Data  compiled  in  l!)l(i. 
Total  cases  Alive. 

traced.  No.  Per  cent. 

17  1  6 

80  12  14 

203  82  31 

551  329  GO 

239  210  90 

Total  .      .      .922          493          53  11.56  040 

It  will  be  seen  that  in  December,  191"),  only  1  of  the  17  cases 
first  seen  prior  to  1900  was  alive,  that  19  per  cent,  of  those  seen 
between  1901  and  1905  were  living,  and  30  per  cent,  of  those  seen 
between  1900  and  1910.  Of  the  552  cases  who  first  came  under  my 
observation  during  the  previous  five  years  there  were  09  per  cent. 
alive.  In  contrast  to  this  table  I  place  alongside  the  figures  brought 
up  to  date  of  December  1,  1910. 

(2)  Duration  of  Life  of  500'  Fatal  Cases  of  Diabetes  with  Actual 
and  Percentage  Mortality. — The  next  table  is  arranged  in  a  similar 
manner  to  the  tables  above  shown  for  the  Massachusetts  General 
Hospital. 

The  duration  of  the  408  fatal  cases  for  the  period  1S93 — December 
1,  191o,  with  the  percentage  fatal  each  year  of  the  disease  is  given, 
and  alongside  are  the  figures  for  500  fatal  cases  for  the  longer 
period,  1S93- December  1,  1910. 

TABLE  21. — THE  DURATION  OF  LIKE  IN  FIVE  HUNDRED  FATAL  CASKS 

OF  DIABETES. 

1S93-1910 

Per  cent.  Number  of  cases.     Per  cent 

10.9  74  14.  S 

17.0  85  17.0 

If).  7  80  10.0 

8.0  41  8.2 

5.0  27  5.4 

5.0  33  0.0 

4.2  27  5  4 

3.2  19  3.8 

4.4  20  4.0 

3.4  19  3  8 

2.4  10  2  0 
2.9  15  3.0 
2.2  11  2  2 
1.0  5  1.0 

1.5  0  12 
1.0  7  1.4 
0.5  3  0  0 
0.7  4  0  8 
0.2  1  0.2 
0.5  5  1.0 

1.7  8        1.0 


Duration,  years. 

Number  of 

0-  1     .      .      . 

.        .        09 

1-  2    .      .      . 

.      .       72 

2-  3 

04 

3-  4 

35 

4     5 

23 

5-  (i     .      .      . 

.      .       23 

0-  7     ... 

.      .       17 

7-  8     .       .      . 

.      .       13 

8-  9     ... 

.      .       18 

9-10     .      .      . 

.      .       14 

10-11     .      .      . 

.      .       10 

11-12     .      .      . 

.      .       12 

12   13     .      .      . 

.       .         9 

13   14     .      .      . 

.      .         4 

1  4-  1  5 

0 

15-10     .      .      . 

.      .         4 

10   17     .      .      . 

2 

17   18     ... 

.      . 

18    19     .       .       . 

.      .         1 

19-20     .       .       . 

2 

20  21  n  m  I  over 

i 

TREATMENT  OF  DIABETES   MELLITUS  37 

Table  21  shows  the  difference  in  the  mortality  of 'diabetes  during 
the  first  year  of  the  disease  between  the  (57.5  per  cent.,  4().(i  per  cent., 
and  47  per  cent,  of  the  early  and  late  Massachusetts  General 
Hospital  statistics  and  the  14.8  per  cent,  of  my  own  cases.  But 
what  is  far  more  important,  it  also  shows  that  the  percentage  of 
cases  of  diabetes  fatal  during  four  of  the  first  five  years  of  the  disease 
is  less  with  the  larger  and  more  recent  series  of  cases.  A  change  in 
mortality  from  16.9  per  cent,  in  the  first  year  of  the  disease  to  14.8 
per  cent,  does  not  seem  large,  but  these  figures,  as  do  those  for  the 
subsequent  years,  understate  the  real  improvement  in  treatment, 
because  to  effect  these  alterations  in  the  statistics  there  were  but 
1)2  new  fatal  cases  to  offset  the  averages  of  the  408  old  fatal  cases. 
These  tables,  to  rny  mind,  present  irrefutable  evidence  of  the 
improvement  in  the  treatment  of  diabetes. 

A  clearer  idea  of  the  duration  of  life  in  diabetes  will  be  obtained 
if  both  the  age  of  the  patient  and  the  onset  of  the  disease  are 
considered. 

The  statistics  have  therefore  been  rearranged  with  this  in  view 
and  in  Table  22  the  duration  of  life  for  patients  with  onset  in  the 
different  decades  is  recorded. 

Inspection  of  the  table  shows  that  nearly  one-half  of  the  cases 
dying  under  one  year'  came  from  the  first  and  second  decades  of 
life.  In  the  discussion  of  the  treatment  of  children,  and  so-called 
acute  diabetes,  attention  will  be  directed  to  the  reason  for  this 
mortality  and  the  means  by  which  it  may  be  reduced.  The  mor- 
tality for  the  other  decades  is  unquestionably  far  higher  than  it 
ought  to  be.  It  is  possible  to  find  support  for  this  statement  by  a 
study  of  Tables  23  and  24  constructed  for  my  living  cases.  There 
it  will  be  seen  that  the  mortality  for  the  first  two  years  of  the 
disease  has  been  reduced  one-half.  It  is  plain  that  the  year  which 
followed  the  discovery  of  the  disease  was  the  diabetic's  danger  zone. 

(3)  Duration  of  Life  of  64'>  Living  Cases  of  Diabetes  with  Actual 
and  Percentage  Mortality, — The  duration  of  life  for  the  living  cases 
both  up  to  December  1,  1915  and  to  December  1,  1916  is  shown  in 
Tables  23  and  24.     The  large  accession  of  new  cases  raised  the  per- 
centage with  a  duration  under  one  year,  but  the  general  tendency  of 
the  table  is  to  show  an  increasing  number  of  cases  who  have  had  the 
disease  over  a  longer  period  than  was  indicated  in  the  statistics  of 
one  year  ago.     Thus,  one  year  ago  the  percentage  over  ten  years 
was  17.9,  and  the  later  series  shows  20.5  per  cent. 

(4)  Comparison  of  Duration  of  Life  by  Decade  of  Onset  of  500 
Fatal  and  640  Living  Cases  of  Diabetes. — Tables  22  and  23  show  the 
actual  duration  of  life  in  years  of  both  fatal  and  living  cases  arranged 
for  comparison  by  decades,  and  as  before  comprise  the  two  series 
of  cases  ending  December  1,  1915  and  December  1,  1910. 


38 


DIABETES  MELLITUS 


- 


— i          |    CO     ,_-' 


TREATMENT  OF  DIABETES  MELLITUS 


39 


M  'C  t-  t  ?l  >n  —  O*       C: 


40 


DIABETES  MELLITUfl 


TABLE  24. — THE  DURATION  OF  LIFE  OF  Six  HUNDRED  AND  FORTY 
LIVING  CASES  OF  DIABETES. 


Duration,  years. 

0-  1 

Number  of 

.      .       29 

1-  2    .      .      . 
2-  3 

.      .       66 
61 

3-  4     .      .      . 
4-  5 

.      .       47 
46 

.">-  6    .      .      . 
6-  7    ... 
7-  S    .      .      . 
8-  9    .      .      . 
9-10    .      .      . 
10-11     .      .      . 
11-12     .      .      . 
12-13 

.      .       43 
.      .       43 
.      .       27 
.      .       24 
.      .       15 
.      .       26 
.      .       10 
12 

13-14     .      .      . 
14-15 

.       .         8 
4 

15-16     .      .      . 
16-17     .      .      . 
17-18     .      .      . 

is-in   .    .    . 

19-20     .      .      . 
20-21  and  over 

7 
.      .        2 
.      .         4 
7 
.      .         4 
.      .        5 

1S9.3    101.' 


1893-1910. 


5.9 
13.5 

12.4 
9.6 
9.4 
8.8 
8.8 
5 .  5 
4.9 
3.1 
5 . 3 
2.0 
2.4 
1.6 
0.8 
1.4 
0.4 
0.8 
1.4 
0.8 
1.0 


cr  of  cases. 

Per  cent 

58 

9.1 

56 

8.8 

61 

9.5 

66 

10.3 

72 

11.3 

60 

9.4 

42 

6.6 

34 

5  .  3 

36 

5  .  (') 

27 

4.2 

31 

4.8 

23 

3.6 

17 

2.7 

10 

1.6 

8 

1.3 

8 

1.3 

4 

0.6 

5 

0.8 

8 

1  .3 

5 

0.8 

9 

1.6 

408 


640 


TABLE  25. — COMPARISON  OF  DURATION  OF  LIFE  OF  FATAL  AND  LIVING 
CASES  OF  DIABETES  BY  DECADE  OF  ONSET.       DECEMBER  1,   1916. 


Age  at  onset, 
years. 


1893-10  Hi. 
Number  of  cases. 


Average  duration,  years. 


Fatal. 


Living. 


0  10 

11  20 

21  :',() 

31  10 

41  50 

51  no 
ni-7o 

71  so 

si  (to 


33 

S.I 

0 

1.x 

37        7 

4 

''2 

3.4 

1.22' 

1  .  332 

4.443 

2  .  59 

4s 

11   .X 

27 

5  .  5 

55       1  1 

() 

40 

(  1  .  2 

2.70 

2  .  75 

2.70 

2.02 

40 

O.S 

50 

10.2 

51       10 

2 

01 

0.5 

3  .30 

3.  O.S 

4.00 

5  .  32 

53 

13.0 

71 

14.5 

(it       12 

s 

94 

14.7 

4.43 

4.42 

6.12 

7.1(1 

71 

17.4 

140 

21).  Xl 

95      1!) 

0 

1X4 

28.7 

0  .  OS 

(1.42 

7.04 

7.28 

07 

23.  S 

120 

24.5 

1  1  5      23 

0 

1(13 

25  .  5 

n.n3 

(1.02 

0.20 

n  .  20 

~>-) 

12.7 

55 

11.2 

(17       13 

4 

(13 

O.S 

0.00 

5  .  Of) 

5  .  3X 

0  .  00 

\  1 

3.4 

1  1 

•>   •) 

in 

2 

12 

1  .0 

3.71 

3.5S 

4.45 

5  .25 

0 

1 

0.2 

1 

0.2 

0.33 

1.33 

Inspection    of  Tahle  2o  slum's  that  the  duration  of  life  of   the 
living  cases   has  already   exceeded  that  of  the  fatal  cases  in  five 


1  If  C;iso  \o.  ss7.  whose  duration  was  twenty-nine  years,  is  ineluded,  the  average 
duration  of  the  ca>es  would  lie  2.0(1  years.  Sec  also  Table  22. 

-  Xot  including  ('ase  \'o.  ss.7. 

n  See  Talile  2-'..  Note  there  were  2  ca.-es  in  the  fir.-t  decade  under  1  year  of  age, 
one  year  ago,  but  now  there  are  <S. 


SEX  41 

decades.  It  is  true  that  in  three  decades  the  living  have  not  lived 
as  long  as  the  fatal  cases,  but  it  must  be  borne  in  mind  that  it  is 
improbable  that  all  these  living  cases  will  join  the  fatal  group 
within  a  year. 

It  is  evident  from  a  comparison  of  the  two  series  of  cases  that 
both  the  duration  of  the  disease  at  the  time  of  death  in  the  fatal 
cases  has  increased,  and  that  also  the  living  cases  show  a  longer 
duration  in  the  statistics  ending  December  1,  1910.  If  the 
tables  serve  as  a  standard  by  which  the  effect  of  new  methods  of 
treatment  can  be  judged  the  labor  in  tracing  the  results  of  past 
treatment  of  11 50  diabetic  patients  will  be  repaid. 


D.     SEX. 

More  men  than  women  are  treated  for  diabetes  according  to  the 
authors,  but  more  women  than  men  die  of  the  disease  according  to 
mortality  statistics. 

In  illustration  of  the  above  I  cite  the  following  table  from  von 
Noorden,1  to  which  I  have  added  my  own  statistics,  and  also  a 
table  showing  the  deaths  from  diabetes  according  to  sex  in  the 
registration  area  of  the  United  States  during  the  years  1913  to 
1915  inclusive.  See  Tables  20  and  27. 


TABLE  26. — SEX  OF  DIABETIC  PATIENTS. 


Xo. 

Males. 
Per  pent. 

Griesinger      
Freriehs    

.      172 

.      282 

76 
70 

Heegen      
Schmitz     
Grube 

.      70(5 
.    1206 
137 

75 

57 
77 

Von  Noorden       .... 

.    1427 

73 

Williamson     

62 

62 

Ki'ilz    

.      526 

76 

Joslin  

.     7:52 

60 

Total  number  and  per  cent. 

.   5252 

67 

Females. 

No.  Per  cent. 

53  24 

118  29 

232  25 

903  43 

40  23 

533  27 

38  38 

166  24 

493  40 


2576  33 


TABLE  27. — DEATHS  IN  THE  REGISTRATION  AREA  OF  THE  UNITED  STATES 

FROM  DIABETES. 

Males.  Females. 

Year.                                              Xo.                  Per  cent.                         Xo.  Per  cent. 

1913 4,537                 47  5,123  53 

1914 4,952                 46  5,714  54 

1915 5,345                 45  6,430  55 


Total  number  and 

average  per  cent.    14,834  46  17,267  54 

1  Von  Noorden:    Loc.  cit.,  p.  57. 


42 


DIABETES  MELLITVR 


1 

_J____ 

5v 

71      _ 

"c3 
o 
H 

•-H   -H   TO   Ci   CO   F-H   1C  t^ 
C-l   Ol   Cl   Cl  CO  •**<  CO 

0 
CN 

Ci  (_ 

^<  >> 

-1    ::::::: 

^H 

in 

**. 

H 
ra 

tn 

—  .  

~-    •/ 

< 

S  ^ 

cc  h 

w 

W 

'' 

ai 

^  2 

< 

"  >. 

P 

^  >> 

W 



/. 

'"'   [2 

S  t 

"  "   >. 

O 

P 

o  * 

-  >. 

(z; 

I.-5    M 
w   >. 

0 

SZi 

H 

<j 

t  S 

— 

o 

oo  2 

K 
P 

— 

H 

- 



P 

-'  >. 

« 

~'   X 

Q 

S!  2 

1C 

Q 

-  i 

g 

«jj 

w  >> 

'•*. 

t  m 

o 

Q 

• 

H 

<N  >, 

.  T"H       .      .      .      .  •"* 

' 

H 

<; 

—  x 

-         — 

-       - 

02 
£ 

o£ 

EH 

ci  >, 

. 

—  •  —  —  — 





• 

cs  £ 

X 

CM  b 

--1  >, 

^ 

0 

Ti  * 

E 

co  £ 

'         ' 

|25 

0 

rt  >> 

K 

• 

>1 

• 

0 

71    H 

K 

C 

f*      tH 

^      >. 

.         .         .         .01         .    T-H         . 

CO 

£ 

5 

o  '!' 
TI  r 

::::--:: 

fl     ^ 

U 
3d 

o  £ 
rt  >> 

:  :  :  :-H  :  :  : 

r- 

1C 

« 

o 

C-.   £ 
>. 

::::-..: 

->     ^ 

Q05 

.-• 

.0  2 

,_,          •          • 

,_, 

>o 

Rd 

• 

<tf  ^ 

.2 

2  h 

rt  .  . 

rt     CO 

O   r-T 

0 

^  "i 

0 

u. 

*-  2 

^ 

rt  >. 

-< 

3 

a  x 

"S 

M  2 

•* 

3  "" 
£  ~> 
•<  s 

K   ~ 

s 

"^  x 

'      '"!-*•      ' 

M     t- 

-^     " 

K  a 
•ff,  ", 

K 
cc   o 

3 

-  >, 

01  2 

-1  >, 

:  :  :  :  SN  :  •*  ; 

0 

01 

?  DIABETES  IN  MALES  AR 
DECEM 

^  >> 

^    ti 
V.    2 

;  \  '.  '.  —  '  n  '.  . 
:  :  :  :—  :  : 
:-  :--oi  :  : 
:  :  i-i-i--1  : 
:  :  :-H(M"s  :  : 
:  :  :^-r'"  :  : 
:  :-t-.'o-  : 
.  —  —  ~i  •-  — 

*     ^ 

7i   h 

0    ^ 

o   -f 

rt     CO 

X    «> 
IM 

O     '^J 
"     CO 

s  OF  DIABETES  IN  FEMALI 
Dt 

—  '  >, 

^^  x 

o| 

«£ 

Is-  ™ 

r^ 

o  ^ 

^•1 
10  ;- 

:    :   :  ^  -H  -M  ^H    : 

'.          !          !          !     r-<     IN     "1*     -H 

—    !  ~-  '    :  TO  -f  -M    ; 
;    ;    ;  M  -H  ci  i^    ; 

<M 

t^ 

X 

-t 
oi 

q 

CO 

•* 

00 
TO 

DO 
CO 
O) 

X 

"•^ 

0 

to 

w 
•£ 

^J 

vj 

J 

** 
H 

"C    tJ 

-r  (-! 
o  L 

"*     CO 
CO     C-. 

^'  t- 

71   l~ 

_     CO 
ro    2 

r^«    c/-1 

H 
W 

O 
J 
H 
fJH 

OS 
Ol 

"**  ^, 
co  2 

r>J 

71      t- 

X 

X 

a  ^ 

Ui"^ 

;  I-H  I-H  IM    !    '.<-*'-< 

rl     <->     TO     "H     _     -f          .          . 

-H  t~  -r  cr.  —  c^  i.o  oi 
ic  •/:  -rfi  -?  t~  •—  -t1     : 

Cl   71    ~    1-   -^   f   Cl   T-H 

CO 

s 

01 

IP 

q 
oi 
01 

iO 

o 
t~ 

X 

M~~ 

6 

O-l 

O) 

i—i  u 

•-  =  '--'-'---< 

t^    ._• 

J 
P) 

T3 

^^ 

W 
J 

a'-  h 

"--•'--*--' 

^!   ^ 

<J 

a 

^    . 

^ 

H 

£  5 

•**   71     £ 

~  ~i  S  ^?  '^  2  1~  x 

~  —  ?i  ro  -r  i.~  -^  r» 

tc      ^- 

H   ^ 

QJ 

3 

o  ^ 
o  — 
-3  o 

>i 

»-H  Ol  CO  T"  10  O  1^  CXD 

1     I 

~o 
H 

CJ 

O 

a 

~     = 

•—-  01  ro  Tt"  >c  o  t^- 

HEREDITY  43 

The  apparent  clinical  preponderance  of  diabetes  in  men  may  be 
ascribed  first  to  the  greater  consideration  which  they  receive, 
second  to  the  large  percentage  discovered  by  life  insurance  examina- 
tions, amounting  to  11  per  cent,  of  my  male  cases,  third  to  the 
hesitancy  of  women  to  speak  about  their  urinary  troubles  and  their 
neglect  to  regard  such  seriously,  and  fourth,  to  the  type  of  practice 
of  those  who  have  reported  large  series  of  cases.  It  is  suggestive 
that  in  Japan  80  per  cent,  of  the  cases  of  diabetes  reported  by  Iwai1 
were  males,  that  70  per  cent,  of  the  German  cases  reported  are 
males,  but  in  England  and  the  United  States  only  (50  per  cent. 
(See  Table  2(».) 

Morrison's2  figures  for  the  city  of  Boston  between  the  years 
1895  and  1913,  like  the  national  statistics,  show  of)  per  cent,  of  1775 
deaths  from  diabetes  to  have  been  females. 

The  fact  that  more  men  than  women  receive  special  medical 
treatment  for  diabetes  and  that  more  women  than  men  die  of  the 
disease  is  evidence  in  favor  of  the  usefulness  of  our  present  thera- 
peutic procedures.  In  Tables  28  and  29  the  duration  of  the  disease 
is  given  for  males  and  females  separately.  These  tables  show  clearly 
the  longer  duration  of  diabetes  in  males. 


E.     HEREDITY. 

The  influence  of  heredity  in  diabetes  has  always  interested  me, 
and  I  have  taken  great  pains  to  secure  data  from  my  patients 
upon  this  point.  Xaunyn  said  that  the  more  carefully  he 
inquired  into  the  family  history,  the  more  commonly  he  found 
heredity  to  be  present,  and  I  am  quite  sure  that  this  rule 
holds.  It  is  easy  to  exaggerate  the  importance  of  heredity,  for 
diabetic  patients  naturally  would  be  more  liable  to  know  of  the 
presence  of  diabetes  in  the  members  of  their  families  than  would 
patients  who  did  not  have  diabetes.  This  introduces  a  considerable 
error  into  the  statistics  of  the  heredity  of  diabetes.  Among  100 
non-diabetic  patients,  Heiburg  found  7  who  had  relatives  with  the 
disease,  and  upon  inquiry  from  100  diabetic  patients  he  learned 
that  18  had  relatives  similarly  affected.  Among  500  consecutive 
histories  of  my  own  non-diabetic  patients  25  had  relatives  with  the 
disease.  Having  seen  the  increase  in  diabetes  in  the  community 
to  be  at  least  in  great  part  apparent  rather  than  real,  I  hesitate  to 
attach  too  much  importance  to  heredity.  Undoubtedly,  heredity 
will  appear  more  prominently  in  the  case  reports  of  diabetes  as 
time  goes  on,  but  this  may  only  reflect  the  greater  accuracy  in  vital 
statistics. 

1  Iwai:  Loo.  cit.,  p.  24.  2  Morrison:  Loe.  pit.,  p.  34. 


44  1)  I A  HE  T  JUS  MELLITUf! 

Statistics  ii])on  heredity  in  diabetes  are  susceptible  to  criticism 
because  of  what  is  included  under  the  term  "hereditary."  I  sus- 
pect that  often  by  this  term  familial  as  well  as  hereditary  cases  are 
included.  So  far  as  my  own  statistics  are  concerned  "heredity" 
signifies  the  presence  of  the  disease  in  a  parent,  and  occasionally 
information  about  a  grandparent  was  obtained,  as  well  as  uncle, 
aunt  or  child.  The  term  "familial,"  on  the  other  hand,  embraces 
brothers,  sisters,  and  cousins  and  it  is  quite  evident  from  the  litera- 
ture that  brothers,  sisters  and  cousins  are  usually  included  in  com- 
piling statistics  on  heredity.  Conjugal  diabetes,  of  course,  does  not 
belong  to  either  group.  In  securing  statistics  upon  heredity,  a 
record  should  always  be  made  upon  the  history  blank  as  to  whether 
the  information  appears  reliable. 

In  4  cases  of  my  series,  Cases  Xos.  105,  473,  50)]  and  954,  the 
diabetes  developed  in  the  child  or  children  before  it  occurred  in 
the  parent. 

The  age  of  onset  and  the  duration  of  the  disease  in  these  four 
cases  to  death  or  the  present  time  is  shown  in  Table  30. 


TABLE  ;•>(). — DIAHKTKS  i\  THE  CHILD  AND  PARENT  COMPARED. 

Child.                     •  Parents. 

Case       AKC  at      Duration,  Case  Afie  at      Duration, 

Xo.         onset,          years.        Condition.  Xo.  onset.          years.  Condition 

IT)             2.S            Dead  :«'.)  47             5.7  Dead 

14             1.4            Dead  47:5  4S             0.2  Dead 

Ml  I             5.1             Alivo  711  54             8 .  X  Alive 
2             1.0            Dead 

12             0.2            Dead  9'54  49              1'°  Allvo 


A  history  of  diabetes  in  grandparent,  parent,  uncle,  aunt  or  child 
was  obtained  in  151  cases  of  my  series — in  other  words,  13  per  cent. 
Of  this  number,  S4  were  males  and  (57  females.  On  the  other  hand, 
the  group  of  cases  showing  a  familial  tendency  included  100  cases, 
or  (S  per  cent,  of  my  series.  Of  this  group,  5!)  were  males,  and  41 
females.  If  we  combine  the  two  groups,  we  have  251  cases  showing 
an  hereditary  or  familial  tendency,  or  21  per  cent,  of  all  the  cases. 
Older  writers  record  data  which  are  similar.  The  fact  that  the 
series  of  cases  of  several  of  these  writers  showed  a  higher  percentage 
of  hereditary  cases  is  interesting.  Personally,  I  believe  that  the 
statistics  on  the  subject  should  be  gathered  with  increasing  care, 
and  that  as  time  goes  on  the  percentage  of  hereditary  cases  will 
constantly  grow.  For  comparison,  Table  33,  taken  in  part  from 
von  Xoorden,  is  inserted: 


HEREDITY 


45 


IO     t~-     O     CO      X      r-     1C     Ol 


H 
- 


CO    -H    M<    X    O    X    —I 


"f       -, 


c  o  o  o  9  c  c 


46  DIABETES  MELLITUS 

1.  Earlier  Statistics. 

TABU:  33. 

Heredity 

Author.  No.  cases.  per  rent. 

Crube 8.0 

FrericJis    ......  10.0 

Seegcn 14.0 

Srhmitz 20.0 

Kill/ C92  21.  (> 

Williamson 100  13.0 

Bouchard 25.0 

Naunyn 39X  17.0 

A.      ^  f  Hereditary.  18.51                    0-   , 

VonXoorclen i  Familial,         <».9J                   2;)'4 

,,,-.  j  Hereditary,  13.01 

•1('slm 11S'  (Familial,        X.O/ 

AVhen  I  personally  examined  the  records  of  the  Massachusetts 
General  Hospital  from  its  formation  until  1SOS,  and  in  connection 
with  Dr.  Fit/  published  the  same,  I  found  that  in  42  cases  the 
question  of  an  inherited  tendency  to  the  disease  was  raised,  and 
this  factor  was  .stated  to  have  been  present  in  ID  cases  and  absent 


'2.  Notable  Diabetic  Families  Showing  Heredity. — The  most 
interesting  diabetic  family  history  that  I  have  encountered  was 
furnished  me  by  a  nurse,  who  stated  that  her  mother  and  her 
mother's  eleven  brothers  and  sisters  all  died  of  diabetes  save  one, 
who,  like  the  rest,  has  the  disease  but  is  still  alive.  Two  of  her 
aunts  each  had  a  child  with  diabetes.  To  my  repeated  inquiries 
about  the  accuracy  of  the  information,  she  writes:  "1  am  positive 
that  diabetes  was  proven  by  examination  of  the  urine  in  the  case 
of  five  of  the  first  generation;  the  others  are  on  record  as  having 
died  of  diabetes.  All  the  patients  were  stout."  (See  Table  34.) 

TABLE  34. 


Preceding 
gone-ration. 

Date  of  birth. 

DateofdoatI 

Duration 
year.- 

of  life,        Ouii-e  of 

death. 

Andrew  . 
I  lannali  his  wile 

.      Oct.    IX,  1X03 
Aug.    9,  1X05 

1X53 
1848 

50 
43 

Lockjaw 
Childbirth 

First  generation: 
Kmilv 

Feb.,    1X27 

1XX1 

54 

Diabetes 

Daniel     .       .       . 

.      Aug.,   1X2X 

1X13 

15 

" 

Hannah  . 

.      Mar.,  1X30 

1905 

/  5 

" 

(leorge     . 
Elizabeth      .      . 

.      Aug.,    1X31 
.      Jan,     1X33 

1890 

1XX3 

59 
50 

" 

Andrew   . 

.      Mav.    1X34 

1X74 

40 

i 

.lane  .... 

.       Feb.,     1X3(1 

189(5 

(i() 

' 

Addie       .       .       . 

.       Dec.,    1X37 

1904 

l>7 

' 

Karhel     .       .       . 

.      Oct.,     1X41 

1X73 

32 

' 

William   .       .       . 

Dec.,    1X13, 

1X95 

52 

' 

John 

Julv,     1X15 

1X7X 

3,3 

n 

Catherine 

Mar.,  1X48 

Living 

52  I 

o  date. 

December,   1915. 

Second  general  ion  : 
.Jennie,  daughter  < 

f  Fli/.abeth       .      . 

.      IX 

Jane,  daughter  of  Family 42 


HEREDITY  47 

The  family  showing  the  most  marked  diabetic  heredity  with 
which  I  have  personally  come  in  contact  was  that  of  a  Jewish 
patient,  Case  No.  759,  who  developed  diabetes  at  the  age  of  fifty- 
five  years.  A  detailed  history  of  this  case  is  reported  on  page 
489. 

A  brother  died  of  diabetes  and  tuberculosis  at  forty-eight  years; 
a  sister  of  diabetic  coma  at  fifty-five  years;  a  sister  of  acute  indi- 
gestion at  fifty-eight  years,  having  had  diabetes  for  many  years; 
a  sister  of  Bright's  disease  at  fifty-six  years,  having  had  diabetes 
for  ten  years;  a  sister,  who  is  living,  has  had  acute  indigestion  and 
also  has  diabetes;  finally  a  brother  died  of  influenza  at  62  years, 
having  had  diabetes  eight  years.  The  father  succumbed  to  paralysis 
at  sixty-two  years,  and  the  mother  to  heart  disease  at  sixty-five 
years.  A  niece,  Case  Xo.  430,  also  has  had  diabetes  for  nine  years, 
during  six  of  which  she  has  been  under  my  observation.  She  became 
pregnant  in  1915,  and  I  am  glad  to  record  that  the  carbohydrate 
balance,  which  amounted  to  15  grams  for  a  year  or  more  before 
pregnancy  began,  rose  to  about  65  grams.  She  had  a  normal  delivery 
in  April,  1910,  nursed  her  baby  for  several  months,  and  both 
mother  and  child  are  in  excellent  condition  (May,  1917).  The 
tolerance  for  carbohydrate  fell  after  delivery  and  again  when  nurs- 
ing was  given  up.  Xo  sudden  change  in  tolerance,  however,  was 
observed. 

3.  The  Favorable  Influence  of  Heredity. — The  influence  of 
heredity  upon  the  disease  is  not  uniform.  It  may  be  serious,  or  it 
may  be  favorable.  Xaunyn  has  pointed  out  that  the  onset  of  the 
disease  in  successive  generations  is  apt  to  take  place  at  a  successively 
earlier  age,  and  consequently  the  diabetes  is  more  apt  to  be  severe. 
Von  Xoorden  has  emphasized  the  importance  of  the  character  of 
the  diabetes  in  the  progenitor  as  indicative  of  the  character  of  the 
disease  in  the  offspring.  My  cases  of  hereditary  diabetes  have 
frequently  been  mild,  and  this  has  so  commonly  been  the  case  that 
I  always  look  upon  heredity  as  a  favorable  omen.  Several  cases 
in  young  people  have  been  unusually  favorable,  and  these  are 
summarized  in  the  following  Table  35,  which  should  be  compared 
with  Table  25,  p.  40. 


TABLE  35. — THE  FAVORABLE  INFLUENCE  OF  HEREDITY  UPON  THE 
COURSE  OF  DIABETES. 

Case  Age  at  Duration. 

XD.  onset.  Hereditary  history. 


203     ...        7             Mother  Alive  10         1 

295     ...      14             Father,  also  brother  Coma  12 

304    .      .      .    .13             Grandfather,   also   2  Coma  9         2 

brothers 

310     ...      17             Mother,  also  brother  Coma  21 

and  sister 


48  DIABETES  MELLITUS 

All  cases  which  have  come  to  my  attention  of  youthful  patients 
with  diabetes  living  for  such  long  periods  of  time  have  been  heredi- 
tary. The  case  of  Sehmitz  quoted  by  Xaunyn1  was  hereditary,  and 
deserves  regard  because  of  its  encouraging  features.  This  was  a 
four-year-old  child,  whose  mother  and  older  sister  were  diabetics. 
The  urine  was  frequently  examined  for  sugar,  and  always  found 
sugar-free,  the  last  examination  being  November  22,  1<S?1.  Novem- 
ber 20,  1S71  a  febrile  attack,  and  evening  urine  of  November  27 
contained  5.X  per  cent,  of  sugar.  Patient  put  upon  a  strict  diet. 
I  >ecember  3,  3.5  per  cent.;  December  <S,  2  per  cent.,  and  on  Decem- 
ber 13,  was  sugar-free.  The  strict  diet  was  continued  for  some 
time,  and  then  gradually  some  bread  and  milk  were  allowed.  Sugar 
was  constantly  absent  from  the  urine,  and  the  child  felt  well. 
The  diet  was  made  more  liberal  from  year  to  year,  and  finally 
included  the  diet  which  most  children  much  enjoy,  fruit,  chocolate, 
and  puddings.  Everything  went  well,  and  at  eighteen  the  strong, 
well-developed  girl  was  married,  and  in  1X92  presented  the  appear- 
ance of  blooming  health,  and  was  the  mother  of  two  healthy  children, 
sugar  having  never  reappeared. 

The  remarkably  favorable  course  of  my  hereditary  cases,  and 
especially  of  the  41  cases  cited,  led  me  to  study  some  of  the  favorable 
cases  reported  by  other  writers. 

Naunyii's  own  famous  cases  Nos.  124,  173  and  32  were  all  heredi- 
tary cases  and  he  refers  on  pages  DO  and  D7  of  his  book  to  other 
cases  of  long  duration  in  which  I  find  that  heredity  was  manifest. 

Teschemacher'2  has  reported  several  cases  of  apparently  cured 
diabetes.  The  most  remarkable  feature  is  the  simultaneous  occur- 
rence of  diabetes  in  all  four  members  of  a  family,  father,  mother, 
and  two  young  children.  It  is  doubtless  a  coincidence1  rather  than 
an  evidence  of  the  infectiousness  of  diabetes.  The  father  slowly 
became  worse;  the  mother  and  both  children  apparently  recovered 
completely;  they  at  any  rate  remained  sugar-free  on  mixed  diet  for 
two  years. 

Riesman3  has  recently  emphasized  the  mild  character  of  some 
cases  of  diabetes  in  children.  Of  the  1  cast's  which  he  reports 
I  again  find  the  presence  of  a  familial  or  hereditary  history  in  three. 
Cases  I  and  II  were  brother  and  sister;  Case  III  showed  neither 
familial  nor  diabetic  heredity,  but  the  mother  of  Case  IV  had  had 
diabetes  for  nine  years. 

The  duration  of  life  of  the  fatal  cases  of  hereditary  diabetes  is 
shown  in  Table  31  and  in  Table  32  are  collected  the  data  of 
those  with  a  familial  history.  The  living  cases  in  each  group 
illustrate  the  improvement  in  treatment. 

1  Xaunyn:   Luc.  cit.,  p.  ,'is-l. 

2  Teschemacher:  Dcutscli.  mcd.  Wchnschr.,  1010,  xxxvi,  p.   101. 

3  Iliesman:  Am.  Juvir.  Mecl.  Sc.,  101(1,  cli.  p.  40, 


HEREDITY  49 

4.  Conjugal  Diabetes. — Nine  instances  (11  cases)  of  conjugal 
diabetes  occurred  in  my  1187  cases.  Oppler  and  C.  Kiilx  found  10 
such  instances  in  900  cases  of  E.  Kill/;  Senator,  among  770  cases, 
found  9  diabetic  couples.  Xaunyn  observed  8  instances  in  775 
cases.  All  agree  that  similarity  of  living  rather  than  contagion 
accounts  for  this  condition,  and  I  subscribe  to  this  opinion. 

Thirteen  of  the  18  individuals  concerned  were  seen  by  me,  and 
only  1  of  these  was  thin;  information  is  lacking  about  the  weights 
of  4;  10  of  the  patients  weighed  165  pounds  or  over,  and  7  from 
190  pounds  to  251  pounds.  These  facts,  together  with  the  duration 
of  the  disease,  are  recorded  in  the  following  table : 

TABLE  30. — COXJUOAL  CASES  OF  DIABETES. 


Case  Duration,  Weight  of 

No.  Sex.  yrs.  inos.  Weight.  consort. 

2    ...  Female  9  .  .  171                      1G5 

10    ...  Male  12  .  .  147                    248 

1111   .      .      .  Female  9  .  .  248                     147 

2342   .      .      .  Male  2  .  .  105                      171 

403     .      .      .  Female  G  1  192 

730    .      .      .  Female  12  G  205 

778    .      .      .  Male  G  1  204 

830     .      .      .  Male  17  .  .  190          Fairly  large,  hut 

not  obese 

832     ...  Female  7  10  251                     200 

1024     .      .      .  Female  8  .  .  103 

1072    .      .      .  Male  8  .  .  175 

The  information  above  given  offers  no  support  to  the  infectious 
theory,  and  makes  it  appear  quite  plain  that  obesity,  probably 
associated  with  lack  of  exercise,  led  to  the  development  of  the 
diabetes.  None  of  the  cases  suggested  to  me  at  the  time  the 
presence  of  syphilis.  A  history  of  gonorrhea  was  obtained  in  one 
instance,  but  this  patient's  wife,  as  well  as  the  wives  of  3  other 
patients,  had  no  miscarriages,  in  contrast  to  four  of  the  women 
who  did. 

5.  Diabetes  in  the  Jewish  Race. — The  evidence  of  heredity 
should  be  greatest  among  Jewish  patients.  Unfortunately  com- 
paratively few  of  these  patients  are  accurately  informed  about 
the  causes  of  death  of  their  antecedents.  However,  the  statistics 
are  as  follows:  Among  151  cases  showing  an  hereditary  tendency 
15,  or  10  per  cent.,  were  Hebrews.  One  hundred  of  my  cases  showed 
a  familial  tendency,  and  13  of  these,  or  13  per  cent.,  were  Hebrews. 
Combining  the  two  groups,  we  find  an  hereditary  or  familial  ten- 
dency among  28  Hebrews,  which  represents  27  per  cent,  of  the  total 
number  of  Jewish  patients.  Thus,  so  far  as  my  statistics  go,  the 
incidence  of  diabetes  in  the  Jewish  race  distinctly  favors  the  etio- 

1  Wife  of  Case  No.  10.  -  Husband  of  Case  No.  2. 

4 


50  DIABETES  MELLITUS 

logical  importance  of  heredity,  because  as  above  said  many  of  these 
patients  were  not  in  a  position  to  know  of  the  causes  of  death  of 
their  relatives. 

The  frequency  with  which  diabetes  occurs  in  the  Jewish  race 
is  proverbial.  Wallach1  found  that  the  death-rate  from  diabetes 
among  the  Jews  in  Frankfort,  as  compared  with  the  deaths  from  all 
other  causes,  was  six  times  greater  among  the  Jews  than  among 
the  other  inhabitants.  Thus  of  14S7  diabetic  patients  treated  by 
von  Xoorden  in  eleven  years,  31.5  per  cent,  were  Hebrews. 

Morrison'1  found  1775  deaths  from  diabetes  in  Boston  between 
1S95  and  1913.  Among  Jews  the  ratio  of  deaths  from  diabetes  to 
the  total  number  of  deaths  was  0.018,  in  contrast  to  0.007  among 
non-Jews.  In  other  words,  diabetes  is  nearly  twice  and  a  half  as 
common  in  this  vicinity  among  Jews. 

The  number  of  Jewish  patients  in  my  series  is  102.  Of  this  number 
there  were  4<S  males  and  54  females,  an  interesting  contrast  to  the 
preponderance  of  males  among  the  total  group  of  patients  which  has 
been  above  recorded.  The  number  of  Jewish  patients  seen  in  each 
successive  100  cases  is  given  in  the  following  table: 

TABLE  '.'>7. — PEKCE\TA<;K  OF  JEWISH  CASES  FOUND  i\  SUCCEEDING; 
CROUPS  OF  100  PATIEXTS. 


4th          f>th          fith          7th  8th          9th          Kith 

100.         100.         100.         10(1.          100.          100.         100. 


,5          3          446          r>         17         11         13         16         8          10 

It  shows  little  more  than  the  increase  in  the  Jewish  population 
in  the  community  during  the  period  of  observation. 

What  is,  however,  of  much  more  interest  than  the  percentage  of 
Jewish  patients  to  the  total  number  is  the  course  which  the  disease 
has  taken  among  these  individuals.  This  is  shown  in  Table  38. 

TABLE  3S.  —  DURATION"  OF  LIFE  OF  THIRTY  FATAL  CASKS  OF  DIABETES 
IN  JEWISH  RACE. 


Df-      I'mlcr       1 
radcs.     1  yr.   I     yr. 


0-  10 
11-20 


31-40 
41-  .")() 


61-70 

71-KJ 


Total 


3 

1 

2 

1 

1 

1                                               1            3 

2          .  .          1 

1          .  .         .  .          1           1          .  .          0 

4 

1            1            1           8 

1                                                                                   1 

1  Wallach:  Deutsch.  mod.  Wrhnsrhr.,  1*93,  xix,  p.  779. 

2  Morrison:  LOC.  cit.,  p.  34. 


THE   CURABILITY  OF   DIABETES  51 

For  the  sake  of  comparison,  the  statistics  for  the  Jewish  patients 
have  also  been  arranged  in  a  table  showing  onset  by  decades,  and 
as  in  former  instances,  the  duration  of  life  of  the  fatal  cases  up  to 
December  1 ,  191(1,  is  given.  It  is  surprising  to  me  that  the  course  of 
the  disease  among  my  Jewish  patients  was  less  favorable  than  the 
general  average.  The  reason  for  this  is  not  clear,  but  I  believe  it  to 
be  due  to  the  fact  that  they  understood  the  diet  less  well,  and  so 
have  paid  the  penalty  of  poor  cooperation. 

The  causes  of  death  of  the  30  fatal  Jewish  cases  were  as  follows: 

Coma 1<> 

Tuberculosis 2 

Cardiorenal  and  vascular 8 

Tonsillitis 1 

Cancer  of  kidney 1 

Suicide 1 

Unknown 1 

30 
F.     THE  CURABILITY  OF  DIABETES. 

The  course  of  diabetes  occasionally  ceases  during  the  lifetime  of 
an  individual,  but  this  happens  very  seldom.  Both  Xaunyn  and 
von  Xoorden  believe  that  a  diabetic  patient  may  recover.  I  am 
unwilling  to  state  that  any  of  my  patients  have  been  cured,  though 
I  am  watching  with  interest  several  cases  of  the  40  now  alive  who 
have  had  the  disease  for  fifteen  or  more  years.  (See  p.  408.)  Other 
facts  regarding  my  own  cases  are  set  forth  in  Tables  23  and  24. 

The  term  "arrested"  instead  of  "cured"  has  found  general 
acceptance  in  the  literature  of  tuberculosis,  and  it  is  equally  appro- 
priate in  diabetes.  It  is  better  for  the  present  to  take  the  con- 
servative stand-point  and  be  very  slow  to  report  cured  or  even 
arrested  cases.  This  has  not  been  done  in  the  past,  and  I  am  con- 
stantly being  told  of  patients  who  have  been  "cured,"  of  which 
proof  does  not  exist.  It  should  be  remembered  that  a  sugar-free 
urine  and  a  normal  blood  sugar  do  not  constitute  a  cure;  both 
should  be  normal  for  years. 

Allen  has  admirably  classified  the  subject,  and  pointed  out  that 
recovery  is  possible  in  three  types  of  cases: 

1.  Acute  Diabetes  Arising  from  Curable  Causes. — It  is  quite 
possible  that  diabetes  which  has  followed  trauma  might  subside, 
either  with  or  without  operation.  Recognizing  the  hyperglycemia 
which  occurs  in  the  course  of  infectious  diseases,  it  is  easy  to  under- 
stand that  in  a  few  cases  glycosuria  may  develop,  last  several 
days,  and  after  recovery  from  the  infectious  disease  may  disappear. 
Schmitz's  remarkable  case,  already  described  on  page  4<S,  might 
come  under  this  heading  and  I  hope  Case  No.  203,  page  52,  will 
prove  to  be  of  this  type.  Undoubtedly  more  cases  of  this  nature  will 


ol?  DIABETES   MELLITl'S 

appear  as  time  goes  on  because  of  the  frequency  of  urinary  examina- 
tions during  the  infections  diseases  of  childhood. 

Local  infections  in  the  neighborhood  of  the  pancreatic  gland,  for 
instance  those  accompanying  pancreatitis  and  gall-stones,  might 
give  rise  to  a  temporary  diabetes.  Thus  Case  No.  IN,  first  seen  by 
me  in  1900,  was  treated  for  diabetes  for  years  by  my  friend,  Dr. 
Pfaff,  and  lived  conscientiously  upon  a  diet.  After  an  interval  of 
fifteen  years,  I  saw  her  again  and  found  the  urine  free  from  sugar 
and  it  remains  so  (January,  1917)  although  the  diet  is  unrestricted. 

Bright's  disease  was  absent.  Careful  inquiry  showed  a  suggestive 
history  of  gall-stones  prior  to  the  diabetes,  and  these  have  recently 
been  disclosed  by  an  .r-ray  examination,  though  at  present  no 
symptoms  exist  which  could  be  ascribed  to  gall-bladder  disease. 
The  patient  has  been  seen  by  me  too  recently  to  obtain  a  detailed 
record  from  Dr.  PfafV.  (See  Table  140.) 

It  is  quite  probable  also  that  a  certain  number  of  cures  will  appear 
in  those  cases  which  have  occurred  as  a  result  of  syphilis.  Such 
statistics  will  be  available  soon.  Ho  many  mild  cases  of  diabetes 
with  Inetic  history  have  occurred  in  my  series  as  to  make  me  watch 
for  syphilis  especially  in  such  patients.  The  outcome  in  these  cases 
will  be  carefully  noted.  (See  Table  l:>9.) 

2.  Exceptional  Cases  in  Childhood. — A  considerable  number  of 
cases  of  mild  or  temporary  diabetes  in  children  is  beginning  to 
appear  in  the  literature.  (See  Kiesman,  already  cited,  p.  4N.) 
Case  No.  203  of  my  series  is  instructive.  This  little  boy  first  showed 
sugar  at  the  age  of  seven,  April  o,  190N,  although  symptoms  were 
present  the  preceding  year.  His  mother  has  diabetes  and  is  Case 
No.  15").  He  was  promptly  put  upon  a  careful  diet  by  his  mother 
and  physician,  Dr.  Warren  \Vhite,  of  Roxbury,  Mass.,  and  has 
remained  sugar-free1  during  the  subsequent  nine  years. 

lie  was  very  faithful  to  his  diet  and  remains  in  good  condition. 
By  advice  he  is  purposely  keeping  a  trifle  underweight  and  eats  a 
normal  diet  except  for  a  little  less  sugar.  The  faithfulness  of  his 
mother  to  her  diet,  maketh  a  doctor's  heart  glad.  Though  she  has 
had  diabetes  sixteen  years  she  "would  not  touch  sugar  any  more 
than  she  would  poison." 

Yon  Xoordeu  reports  a  striking  case  of  a  seven-year-old  boy 
who,  on  a  strict  diet,  constantly  excreted  20  to  HO  grams  of  sugar 
and  considerable  quantities  of  acetone  bodies.  lie  became  sugar- 
free  only  with  the  help  of  oatmeal  and  vegetable  days,  lie  remained 
on  this  restricted  diet  for  some  years  and  at  the  age  of  twelve  years 
was  again  seen  by  von  NOorden,  when  he  was  in  perfect  health, 
eating  an  ordinary  diet  without  a  trace  of  glycosuria. 

H.  Diabetes  Associated  with  Organic  Diseases.  This  group  is 
subdivided  bv  Allen  into  (1)  those  cases  with  nervous  disorders, 


ETIOLOGY  OF  DIABETES  53 

such  as  the  cases  described  by  Naunyn  in  association  with  tabes. 
(2)  Cancer  involving  the  pancreas  which  may  be  followed  by  the 
disappearance  of  sugar.  Xo  instance  of  this  kind  has  occurred 
in  my  practice.  (3)  Xeither  have  I  observed  cirrhosis  of  the  liver 
replace  the  diabetes,  such  as  Claude  Bernard  and  Lepine  describe. 

(4)  On  the  other  hand,  with  the  development  of  severe  nephritis, 
diabetes  has  ceased  in  a  few  cases,  notably  Case  Xo.  354  (see  page  29) . 
In  Cases  Xos.  457  and  872  (p.  418)  it  developed.     (5)  The  fifth 
group  mentioned  by  Allen  is  tuberculosis.     Xaunyn  and  many  other 
writers   have   observed  the  subsidence  and   disappearance  of  the 
disease  following  tuberculous  infection.    I  would  refer  to  Case  X'o. 
344  of  my  series  (see  page  410).    In  this  patient  the  severest  degree 
of  diabetes,  as  shown  by  the  urinary  analyses  of  December  25-20, 
1911,   changed  its  character  entirely,   as  proven  by  the   urinary 
reports  of  March   17-18,    1912.      During  the  interval  pulmonary 
tuberculosis  broke  out  and  advanced  rapidly.     AYeight  decreased 
from  147  pounds  to  the  neighborhood  of  80  pounds  and  the  patient 
died  without  acidosis.    Many  diabetics  are  cachectic  at  the  time  of 
death,  but  this  condition  by  no  means  has  modified  the  disease. 
On  the  other  hand,  when  cachexia,  due  to  other  causes  than  diabetes, 
occurs  in  a  diabetic,  it  may  be  responsible  for  improvement  in  the 
diabetes. 

G.     ETIOLOGY  OF  DIABETES. 

In  any  discussions  of  the  etiology  of  diabetes  it  is  recognized 
that  some  fundamental  disturbance  in  the  metabolism  is  at  fault, 
presumably  associated  with  the  pancreas.  This  is  the  cause  of 
diabetes.  In  the  discussion  which  follows,  various  factors  pre- 
disposing to  the  development  of  diabetes  are  considered.  They  are: 
(1)  obesity,  (2)  dietary  excesses,  (3)  multiple  etiology,  (4)  heredity, 

(5)  strenuous  life,  (())  nervous  element,  (7)  infections,  (8)  arterio- 
sclerosis, (9)  syphilis,  (10)  trauma,  (11)  pancreas,  (12)  hypophysis, 
(13)  liver,  (14)  renal  glycosuria,  (15)  gout. 

1.  Obesity. — In  over  40  per  cent,  of  1063  of  my  own  cases  avail- 
able for  statistics  in  this  respect,  marked  obesity  has  preceded  the 
outbreak  of  diabetes,  and  if  my  early  data  were  more  exact  I  believe 
that  the  percentage  would  be  fully  twice  as  great.  Contrariwise,  in 
the  presence  of  wasting  disease  diabetes  is  practically  unknown. 

One  of  the  most  striking  instances  is  that  of  a  little  child,  Case 
Xo.  1139,  a  healthy  baby  until  his  second  year,  when  he  entered 
upon  a  series  of  rhinopharyngeal  and  bronchial  attacks,  including 
a  mild  bronchopneumonia.  During  eleven  of  these  feverish  ill- 
nesses, exercise  was  curtailed  and  he  was  kept  abed  to  safeguard  his 
heart.  A  cow  was  bought  that  he  might  have  fresh,  rich  milk,  and 
to  the  50  ounces  of  this  milk  which  he  daily  consumed  were  added 


54  DIABETES  MELLITUS 

three  tablespoonfuls  of  a  malt  preparation,  amounting  in*nutritive 

value  to  120  or  more  calories.  At  the  end  of  his  first  year  lie  was  of 
normal  weight,  but  at  eighteen  months  his  weight  was  above  that 
of  a,  child  of  two  years.  When  two  years  old  his  weight  had  increased 
to  that  of  ii  child  of  three  years  and  a  half,  and  when  two  years  and 
a  half  old,  his  weight  was  above  that  of  a  child  of  four  years.  Is  it 
surprising  that  when  mumps  developed,  glycosuria  appeared?  It 
vanished  with  a  change  in  diet,  to  return  threemonths  later,  during  the 
presence  of  another  mild  febrile  disorder, and  again  in  six  months  after 
the  removal  of  adenoids,  but  si  nee  the  urine  has  remained  sugar-free. 

Kisch1  directed  attention  to  the  frequency  of  the  development  of 
diabetes  in  the  later  lives  of  fat  children,  and  1  never  see  a  fat  child 
without  thinking  of  this  possibility,  for  a  fat  child,  like  a  fat  man, 
is  prone  to  diabetes.  Particularly  serious  must  it  be  for  a  child  or 
adult  of  slight  stature  to  put  on  weight  which  would  be  excessive 
even  for  a  man  of  large  frame.  Case  Xo.  1142  first  consulted  me 
at  the  age  of  forty-one  years,  and  1  can  just  remember  his  little 
spindling  legs  and  delicate  frame  as  a  boy  before  he  entered  the 
primary  school;  many  years  later  lie  entered  a  grocery  store, 
"worked  like  the  dickens  and  ate  the  .same  way,"  until,  at  the  age 
of  forty  lie  was  00  pounds  above  the  average  weight,  and  sugar  was 
found  at  a  life  insurance  examination. 

Of  oOS  applications  for  life  insurance  rejected  for  obesity 
Romanelli2  reports  21  per  cent,  as  having  glycosuria. 

A  poor  musculature  usually  accompanies  obesity.  One-half  of 
the  carbohydrate  in  the  body  is  stored  in  the  muscles  and  a  large 
part  of  the  sugar  of  the  body  is  burned  in  them.  Therefore  it  does 
not  appear  strange  that  fat  people  develop  diabetes.  It  would 
almost  seem  as  if  the  muscles  became  so  loaded  with  fat  that  they 
were  unable  to  burn  carbohydrate.  ^ 

It  is  a  serious  matter  to  get  fat.  One  of  my  thin  relatives  whose 
religion  was  not  of  the  eut-and-dried  type  used  to  laughingly  say  to 
her  fat  but  pious  sisters-in-law,  "To  get  fat  shows  a  lack  of  moral 
character."  And  my  learned  friend  who  supplies  me  with  epigrams 
says,  "Laugh  and  grow  fat—  grow  thin  and  laugh  longer,"  and  also, 
"What  is  added  to  the  waist  line  is  cut  from  the  life  line." 

i\Iy  own  cases  have  been  analyzed  in  two  ways  to  show  the 
incidence  of  obesity  prior  to  the  development  of  diabetes.  Of  the 
lOni)  cases  available  for  the  purpose  above  the  age  of  twenty  years, 
I  considered  from  the  appearance  and  history  that  obesity  was  or 
had  been  present  as  an  etiological  factor  in  4  1  per  cent.  It  is  possible, 
however,  to  arrive  at  a  more  definite  conclusion  from  the  examina- 
tion of  a  table  constructed  to  show  the  average  highest  weights  at 
given  heights  of  a  large  number  of  male  and  female  diabetics.  Such 

1  Ki-ch:.Inur.  Am.  Mcd.  .\ssii.,  March.  I'.H.V  Ixiv,  p.  Kl.'is. 

2  Romaiu'lli:  .lour.  Am.  Mcd.  Assn.,  I',)!,"},  Ixv,  p.  HI.". 


TABLE  39.- 


-A  COMPARISON  OP  THE  AVERAGE  HEIGHT  AND  WEIGHT  OF 
NORMAL  AND  DIABETIC  INDIVIDUALS. 


Weight. 

IIei8ht-                         Normal.'                                             Diabetics  (K.  P.  .1.). 

(Shepherd). 

Male. 

Female 

Ft. 

In. 

Cm. 

Lbs. 

Kg. 

No.  of 
cases. 

Lbs. 

Kg. 

No.  of 
eases. 

Lbs.           Kg. 

Ages  15 

to  24 

4 

10 

147.3 

0 

0 

4 

11 

149.9 

0 

0 

5 

0 

152.4 

120 

54.5             1 

150 

70  .  8 

2 

105           47  7 

5 

1 

154  9 

122 

55  4              0 

0 

5 

2 

157.5 

124 

55  .  8 

0 

3 

110 

49.9 

5 

3 

100.0 

127 

57  .  0 

0 

2 

117 

53  .  1 

o 

4 

102.0 

131 

59  .  5 

0 

o 

105 

47.7 

5 

5 

105.1 

134 

00  .  8              1 

157 

71.3 

0 

5 

0 

107.7 

138 

02.0             3 

139 

03  .  1 

1 

119           54.0 

5 

7 

170.2 

142 

04  .  4              2 

141 

04.0 

2 

147              ;            00.7 

5 

8 

172.7 

140 

06.3             8 

148 

67.2 

0 

5 

9 

175.3 

150 

68.  1             4 

182 

82.6 

0 

5 

10 

177.8 

154 

09  .  9     i         1 

101 

73.1 

0 

5 

11 

180.3 

159 

72.2              0 

1 

136           01.7 

(i           0 

182.9 

105 

74.9             3 

191 

80  '.  7 

0 

(i            1 

185.4 

170 

77.1 

1 

148 

07.2 

0 

0            2 

188.0 

170 

79.9 

1 

200 

90  .  7 

0 

(i 

3 

190.5 

181 

82.1 

0 

0 

Averag 

e  number 

of  poum 

s  overwei 

glit  of  38 

diabetics  —  3  pou 

lids. 

Ages  25 

to  29 

4 

11 

149.9 

0 

1 

120 

54  .  5 

5 

0 

152.4 

125 

56.7             0 

0 

5 

1 

154.9 

120 

57.2             0 

0 

5 

2 

157.5 

128 

58  .  1             0 

0 

58  .  1 

5           3 

100.0 

131 

59  .  5             0 

1 

128 

5           4 

102.0 

135 

61.3             0 

1 

248 

74.9 

5           5 

105.1 

138 

02.0     ,         1 

210 

1               105 

75.3 

5           6 

107.7 

142 

04  .  4              4 

101 

73.1 

2              166 

66  .  3 

5           7 

170.2 

147 

06.7             3              158 

71.7 

1               146 

5 

8 

172.7 

151 

08.5             3              170 

79.9 

0 

5           9 

175.3 

155 

70.3             2              173 

78.5 

0 

o          10 

177.8 

159 

72.2              2               141 

04.0 

0 

5     i     11 

180.3 

104 

74.4             4              100 

72.0 

0 

(i           0 

182.9 

170 

77  .  1              1              208 

0 

6            1 

185.4 

177 

80  .  3             1              200 

90  '.  7 

0 

0           2 

188.  0 

184 

83.5 

0 

0 

0           3 

190.5 

190 

86  .  2             0 

0 

Average  number  of  pounds  overweight  of  27 

diabetics  —  51    pounds. 

1   Ages  30   to  39 

4          11        149.9 

0 

1              125           50.7 

5           0 

152.4 

129 

58  .  5             0 

0 

5     !        1 

154.9 

130 

59  .  0             0 

3              140           03.5 

o            2 

157.;'          132 

59  .  9             0 

2              123           55.8 

5           3 

100.0 

13-5 

61.3             0 

4              103           74.0 

5           4 

162.  i',  i       139 

63.1             2              140 

(Hi  .  3 

1              250 

5            5        105.  1          142 

64.4             3              171 

77.0 

4              109           70.7 

5            (i        1(17.7          140 

66.3             3              177 

80.3 

3              191      ,     80.7 

5            7 

170.2 

151 

68.5             7              179 

81.2 

1              178 

80.8 

5            8 

172.7 

155 

70.3             7              175 

79.4 

1               145 

05  .  8 

5           9 

175.3 

160 

72.8 

6 

172 

78.1 

0 

5          10 

177  .  8 

105 

74.9 

7 

131 

82.1 

1              225 

5 

11 

180.3 

171 

77.6 

10 

193 

87  .  0 

4              212 

0 

0 

182.9 

177 

80.3 

2 

181 

82.1 

0 

6 

1 

185.4 

183 

83.0 

1 

135 

88.5 

0 

0 

2 

188.0 

190 

86.2 

0 

0 

6 

3        190  .  5 

197 

89  .  4             0 

0 

Averag 

•  number 

of  pounds  overweight  of  721   diabetie 

s^23  po  uncls. 

Ages  40   and  over 

4 

10 

147.3 

0 

4               179 

81.2 

4 

11 

149.9 

0 

5               181 

82.1 

5 

0 

152.4 

133 

00  .  4 

2                1S8 

85  .  3 

16              172 

78.1 

5 

1 

152.9 

135 

61.3 

1               174 

79  .  0 

11               175 

79.4 

5 

2 

157.5 

13S 

62.6 

0                ..' 

14               109 

70.7 

5 

3 

100.0 

141 

(i  t  .  0 

0 

14               180 

81  .7 

5 

4 

102.0 

144 

65.4 

4              187 

84  '9 

14               171 

77.0 

5 

5 

105.1 

148 

07.2 

12 

178 

80.8 

17               209 

94  .  8 

5 

6 

107.7 

152 

69.0 

20 

183 

83.1 

1  1               190 

80.2 

5 

7 

170.2 

150 

70.8 

24 

204 

92  .  6 

3               199 

90.3 

5 

8 

172.7 

101 

73.1 

39 

200 

90.7 

4               207 

93.9 

5 

9 

175.3 

166 

75.3 

42 

211 

1               222 

5 

10 

177.8 

171 

77.0 

18 

218 

0 

5 

11 

180.3         177 

80.3 

.     20 

212 

3              230 

6 

0 

182.9         183 

83.0           17 

235 

0 

6 

i 

185.4 

190 

86  .  2             2 

337 

0 

6 

2 

188.0 

190 

88.9             4 

225 

0 

6            3 

190.5 

201           91.2             1 

270 

0 

Average  number  of  pound  ,s  overweight  of  320  diabetics  —  37   pounds. 

1  Shepherd:    Med.  Examiner,  1899,  ix,  p.  209. 


Dl  A  BE TES  MELLIT US 


a  table  has  been  prepared,  and  for  eomparison  Shepherd's  Table  of 
Height  and  Weight  of  Healthy  Adults  is  placed  alongside  (Table 
30).  I  have  not  a  very  satisfactory  collection  of  heights  and  weights 
of  diabetic  children,  but  the  question  is  so  important  that  I  append 
the  standard  height  and  weight  table  of  healthy  children  selected 
by  Dr.  John  L.  Morse  for  his  (1aw  Histories  in  Pediatrics.  (Pub- 
lished by  \Y.  M.  Leonard,  Boston,  1913.) 

TAHLK  40. — HKICHTS  AND  WEIGHTS  OF  CHILDKRX. 


Height. 

Weight. 

Age. 

Boys. 

Girls. 

Boys 

Girls. 

Inches.            Cm. 

Inrhes. 

Cm. 

Pounds. 

Kg. 

Pounds. 

Kg. 

Birth1 

20.0          52.") 

20.5 

52.2 

7  .  55 

3  .  43 

7.10 

3  .  20 

1  year 

29  .  0           73  .  X 

2S.7 

73  .  2 

21.0 

9  .  54 

20.5 

9.31 

2  years 

32  .  r>        ,s2  .  s 

32  .  5 

S2  .  s 

27.0 

12.27 

20.0 

11.81 

3  vcars 

35  .  o        89  .  i 

35  .  0 

89  .  1 

32  .  0 

14.55 

31.0 

14.09 

4  yoars 

38  .0          90  .  7 

3S  .  0 

96.7 

30.0 

10.30 

35  .  0 

15.90 

The  heights  and     weights  in  this  table  are  net;     i.  f., 

without 

shoes   or 

clothes. 

A>_'<>  at 

last 

birthday. 

5  years 

41.7        105.9 

41.3 

104.9 

41.0 

18.6 

39  .  0 

18.0 

0  years 

43  .9        111.5 

43.3 

110.1 

45  .  2 

20  .  5 

43.4 

19.7 

7  years 

40.0        HO.s 

45  .  7 

116.0 

49.5 

22.5 

47.7 

21.7 

8  years 

48.8        123.9 

47.7 

121.1 

54  .  5 

24.7 

52  .  5 

23.8 

9  years 

50.0        127.0 

49  .  7 

120.2 

59  .  0 

27.0 

57.4 

20  .  0 

10  years 

51.9        131.  S 

51.7 

131  .3 

05  .  4 

29  .  5 

62.9 

2S  .  5 

1  1  years 

53.0         130.1 

53  .  8 

130.0 

70.7 

32  .  1           09  .  5 

31.5 

12  years 

55.4        140.7 

50  .  1 

142.4 

70.9 

34  .9          7S  .  7 

35.7 

13  years 

57.5        140.0 

5s  .  5 

14S.5 

84.8 

3S  .  5           8S  .  7 

10.3 

14  years 

00.0         152.4 

00  .  4 

153.4 

95.2 

43.2 

9<S  .  3 

44.0 

15  years 

02.9        159.7 

01.0 

150.4 

107.4 

4s.s 

IOC).  7 

48.5 

It)  .years 

04  .  9         1  04  .  S 

02  .  2 

157.9 

121.0 

55.0         112.3 

51  .0 

.•  \\nii  iiiiiixii   I-IDI  ni->.      Those  make  up  for  boys  approximately  S 
per  cent.,  and  fo    girls  7  per  cent.,  of  the  gross  weight. 

The  term,  ''ag  at  last  birthday,"  is  liable  to  give  a  wrong  impression,  because  the 
figures  given  are  vally  average  figures  taken  from  all  the  children  from  that  birthday 
to  the  next.  A  lore  accurate  term  is  the  succeeding  half-year;  age  approximately 
for  succeeding  half-year,  ;'.  c..  five  and  a  half  years  instead  of  live  years,  the  age  at 
the  last  birthday. 

A  study  of  the  tables  plainly  shows  that  the  average  diabetic, 
whether  nude  or  female,  has  been  greatly  overweight.  In  only  four 
of  the  forty-three  groups  is  there  an  exception  to  this  rule.  With 
these  facts  before  him,  what  an  opportunity  for  the  general  prac- 
titioner to  practise  preventive  medicine. 

The  question  of  overweight  is  of  importance  in  a  far  broader 
field  than  diabetes,  and  for  that  reason  I  insert  from  the  Traux- 
actionx  <>/  flu1  Actuarial  Socicfi/  of  America  the  mortality  figures  of 
a  large  series  of  individuals  according  to  their  weight  and  height. 
This  table  shows  convincingly  the  danger  of  overweight. 

1  The  data  for  the  first  lour  years,  taken  by  Morse  from  Holt's  "Diseases  of 
Infancy  and  Childhood,"  are  here  given  as  published  by  Holt  in  his  7th  edition. 


ETIOLOGY  OF  DIABETES 


C5  s  i  -= 

£g!    1 

•<   X  o 

§W    c  I 

S  j  i      S 

S  •<  -S         - 


x  x  o      ooo]      o]  o-)  co      —  —  i 


.0  LOO       CCO)       OOt^       LOOO       O)  O)  O 
O  O  —       —  —  O)       O  C  C       OOO       XXX 


H)  C)  o        O5  o  Ci        XXX 


CMOO 

0)  M  T 


•  X       X  X  O       XXX 


•-O  C  LO        a  —  CO        —  —  t 


—  CM  CO 

coxo 

—  — I  CO 


LO  o  co     o  a  • 


—  —  -O        O)  CO  IO        CO- 


3S2-S 

ris 


o  o  t-      01  01  o)      -*  —  —      co  c  LO 

LO  LO  IO        Tf  -f  Tf        CO  CO  CO        CO  CO  01 


OO—       —  —  ', 


—  0>)  '— '        O 


CO  CO  CO         TO  Ol  O)         CO  O)  CM 


x  x  —      oxx     en  0)  —     t»  c.  >.i 

CO  CO  -f        COO1O)        CM  CM  CM        CM  —  — 


00  —  -t       LO  X  b-       XOO       —  CO  -f       X  O  X       t~  O  i 

OO—         CO—         —  —  CO         COCOTf         CO  •*  •*         COCO- 


CM  CM  CM        CM  —  —        CM  —  — 


OC—         —  —  CM         O)O)CO         COCOCO         COCOCO         O)  CM  CO         O)O]CM         CM' 


~  2 -    22- 

CO  O  O        X  O)  O 

OOO       OO—       OO  — 


CC  X  X       O  C  O 

ooo     o  o  c 


o  o  c     c  o  c     o  o  c 


o  o  LO      -f-p-i     r^xx     oxx      —  r^  t-     -*^i 

COO   000   CCO   COO   —00   — Cc 


ooc 

C-)CMO 


1  —    0)0)0)    -f  M  O)    X  O)  O)    —  • 


o  o  ooc  c  o : 


OOO   OOO   —CO   — OO 


>o  to  c   ~  ~  x  xxx  cox   —ox 


mo  —   01  o  o 


oc—  ooo  ooo 


OOO   OOO   OOO   XOO   O  O  X 


OXX   C.  XX   OXX 


C   C.  O  O   XOO   XXX   XXX   OXX   OXX   OXX 


<  CM         O  — 


c;  c  —      tccox      cox—      c  —  >o 


o  -r  co      O)  —  . 


OOO       OOO       OOO       XXX       XXX        XXX       OXX       OXX 


CO!  CO 

O)  X  t^ 

—  Ol  CO 


o  o      xxx      xxx      b  x  x      b  x  x 


:  —  01      o  c  —      ooo 


C. 


OO   XXX   XXX   OXX   OXX 


—  co  —  o  —  o")  c  —  —  ooc  o  o  b 

0  iO  rf  O  CM  O  *»•  M  OC  O  LO  t^  LO  O  O 

01  co  —  —  01  01  o  —  —  o  c  c  ooc 
-tox  cooio  xoco  -tcoi  t-co^t 


OOO   XXX   XXX   OXX   OXX 


OOC   OOO   O  O  X   OXX   OXX   OXX 


5S  DIAHKTEfi   MELLITUS 

Table  41  is  at  first  confusing.  Tt  shows  the  percentage  of  mor- 
tality in  the  community  for  different  ages  and  heights  according  to 
whether  the  individual  is  below  or  above  the  average  standard 
weight  for  the  given  height.1  Tims,  the  liability  of  death  of  an  indi- 
vidual forty  years  of  age,  under  five  feet  seven  indies  tall,  who  is  of 
standard  weight  (see  Shepherd's  Table,  p.  .">.">)  is  only  !Ki  per  cent,  on 
the  basis  of  the  mortality  for  all  of  this  age.  If  he  is  fortunate  enough 
to  be  10  or  even  1")  pounds  under  weight,  his  liability  for  death  is 
reduced  to  SO  per  cent.,  but  if,  on  the  contrary,  he  weighs  15 
pounds  above  the  standard,  his  misfortune  raises  his  liability  to 
death  to  104  per  cent.,  and  if  ">()  pounds  over  weight,  to  1.">1  per 
cent.  The  patient  in  my  office  today,  as  I  write  this,  saw  that  with 
his  weight  of  oOO  pounds  his  chance  for  death  had  more  than 
doubled,  and  it  was  unnecessary  for  me  to  urge  him  to  cat  less. 
It  is  obvious  that  one's  chance  for  life  is  increased  after  the  age  of 
thirty-five  by  being  lo  to  20  pounds  underweight,  and  that  obesity 
carries  with  it  an  invitation  to  death. 

TABLK  42. — KXPF.CTATIOX  OF  LIKK — AMF.KICAX  TABI.K. 
Exp. 

48.72 

48.  OS 

12  47.  If) 
i:{  Hi.  so 
11  Hi.  Hi 

I.'.  45.50 
1C.  44.s.r) 
17  14.1!) 

is  1.T53 

19  12. S7 

20  12.20 

21  41.53 

22  10. So 
2:5          10.17 
21          159.19 
2:,        3s.si 
2C.          :5S.12 

27        :57.K5 

2s  :5C..7:5 

29  :5(i.o:5 

:5t)  :55.33 

::i  :5i.c.:5  53        is.  79  7r>          ti.27 

The  remark  is  often  heard  that  from  middle-life  onward  the 
advent  of  diabetes  does  not  tend  to  shorten  the  life  of  the  individual. 
To  this  general  statement  I  cannot  agree.  It  is  true  that  the 
restricted  diet  often  exerts  a  most  beneficial  influence  upon  not  only 
the  diabetes  but  also  upon  obesity,  heart  disease  and  an  accompany- 
ing Hright's  disease,  yet  on  the  whole  as  yet  we  cannot  advise1 
patients  to  endeavor  to  contract  diabetes  in  order  to  live  long.  'Flic 
expectation  of  life  of  patients  is  not  sufficiently  considered  by 

1  This  table  is  to  he  u-ed  in  conjunction  with  Shepherd's  t:il>lr.  (Sec  Table  .'59.) 
It  may  lie  as-limed  that  normal  women  between  the  ;im>s  of  fifteen  and  torty- 
fonr  \veiiili  about  MX  p  >und-  le-<  than  men,  and  after  that  at:e  about  three  pound- 
less.  For  a  careful  .-tu<!y  of  ilie  weights  of  women  see  Weisse,  Medical  Record, 
1909,  Ixxv,  p.  13. 


Age. 

Exp. 

Ago. 

E 

xp. 

54 

IS. 

09 

7(1 

,) 

,88 

.").") 

17. 

40 

77 

r> 

49 

50 

16, 

-•> 

7s 

5 

.11 

57 

16 

05 

79 

4 

.74 

58 

15, 

39 

SO 

4 

.39 

59 

14 

74 

8] 

4 

.05 

()(  ) 

14 

10 

S2 

3 

.71 

til 

13 

.47 

S3 

3 

.39 

C.2 

12 

.86 

si 

3 

IIS 

c,:5 

12 

,26 

S5 

•> 

*  i 

til 

11 

.67 

80 

•> 

.47 

05 

11 

10 

s7 

•> 

.18 

00 

10 

54 

ss 

1 

.91 

07 

10 

,00 

S9 

1 

.60 

OS 

9 

.47 

90 

1 

.42 

69 

s 

.97 

91 

1 

.19 

70 

s 

IS 

92 

0 

.98 

71 

s 

,00 

9.H 

0 

,80 

72 

7 

55 

94 

0 

64 

7:1, 

t 

,11 

95 

0 

50 

74 

(•) 

c.s 

ETIOLOGY  OF  DIABETES  59 

physicians,  and  for  my  own  benefit  as  well  as  others  I  insert  Table 
42,  the  American  Fxperience  Mortality  Table.  A  study  of  this  table 
will  show  how  many  years  we  often  fall  short  of  the  normal  expec- 
tation of  life  in  our  present  treatment  of  diabetes,  and  it  sets  a 
goal  to  which  we  must  aspire  with  each  case. 

2.  Dietary  Excesses. — Dietary  excesses  figure  quite  prominently 
in  my  records  as  precursors  of  diabetes.  Allen's  dogs  artificially 
predisposed  to  diabetes  by  removal  of  a  considerable  portion  of  the 
pancreas  became  diabetic  when  overfed.  It  is,  however,  the  excess 
of  food  rather  than  of  carbohydrate  which  does  the  harm.  Indeed, 
a  high  percentage  of  carbohydrate  in  the  diet  does  not  appear  to 
predispose  to  diabetes.  Thus,  the  Japanese  live  upon  a  diet  con- 
sisting largely  of  rice  and  barley,  yet  so  far  as  statistics  show,  the 
disease  is  not  only  rare  but  mild  in  that  country.  Four  years  ago 
Germany  consumed  half  as  much  sugar  as  was  eaten  in  the  United 
States,  and  yet  diabetes  was  quite  as  prevalent  there  as  here.  The 
increase  in  the  quantity  of  sugar  consumed  per  capita  in  the  United 
States  during  the  last  century  is  very  great,  as  shown  by  Table  43, 
and  when  one  compares  this  table  with  the  rising  incidence  of 
diabetes  shown  in  Tables  1  -4,  it  would  seem  as  if  the  two  must  stand 
in  relation.  Fortunately,  the  dietary  habits  and  the  statistics  upon 
diabetes  of  Japan  would  seem  to  save  us  from  this  error,  but  I  am 
not  quite  convinced,  and  shall  be  glad  to  study  the  more  accurate 
figures  for  the  incidence  of  diabetes  in  countries  where  carbohydrate 
food  is  predominant,  which  will  come  with  time.  It  will  also  be  of 
interest  to  learn  the  incidence  of  diabetes  of  workers  in  candy 
factories. 

The  marked  increase  in  the  consumption  of  sugar  shown  in 
Table  43  might  appear  of  great  significance  in  seeking  for  a  cause 
of  the  greater  frequency  of  diabetes  today  were  it  not  for  the  fact 
that,  whereas  the  consumption  of  sugar  per  capita  between  1900- 
1917  has  increased  17  per  cent.,  the  mortality  from  diabetes  has 
nearly  doubled.  Nevertheless,  such  a  marked  alteration  in  the  diet 
of  a  nation  is  noteworthy  and  deserves  attention. 

TABLE  43. — THE  CONSUMPTION  OF  SUGAR  IN  THE  UNITED  STATES, 
1800-1917. 

Population  Pounds  per 

average  for  Tons,  capita, 

Years.  decade.  yearly  average.         yearly  average. 

1800-1810  ....  6,146,343  33,952                   '  11 

1810-1820  ....  8,280,041  35,152  8 

1820-1830  ....  11,038.448  47,930  9 

1830-1840  ....  14,720,126  85,055  12 

1840-1850  ....  19,824,542  158,995  2 

1850-1860  ....  26,905,025  350,653  26 

1860-1870  ....  34,645,094  391,013  23 

1870-1880  ....  43,777,206  732,758  33 

1880-1890  ....  55,912,152  1,233,408  44 

1890-1900  ....  68,818,801  1.920,886  56 

1900-1910  ....  83,275,548  2,722,048  65 

1910-1917  ....  97,837,494  3,568,014  73 


GO  DIABETES  MELLITUS 

3.  Multiple  Etiology.  The  majority  of  diabetic  patients  preseirt 
multiple  causes  for  their  diabetes.  This  is  well  exemplified  by  the 
history  of  a  gentleman,  aged  forty-nine  years,  Case  No.  054,  who 
consulted  me  on  December  12,  1915.  One  of  his  children  died  in 
1001  at  the  age  of  two  years,  and  another  in  1013  at  the  age  of  twelve 
years,  both  of  diabetes.  As  a  child  he  had  measles,  scarlet  fever, 
and  whooping-cough,  und  at  twenty-four  years  was  ill  for  eighteen 
months  with  inflammatory  rheumatism,  and  the  pericardium  was 
tapped  twice. 

At  the  age  of  thirty-three  years  his  weight  was  200  pounds,  and 
for  his  height— 5  feet  11  inches — was  17  per  cent,  above  normal. 
Prior  to  this  time  he  indulged  in  considerable  alcohol  three  evenings 
a  week,  and  his  use  of  tobacco  has  been,  more  than  moderate.  lie 
was  fond  of  sweets  and  occasionally  ate  half  a  pound  of  candy  in  an 
evening.  During  the  last  two  years  he  took  little  exercise,  and 
recently  led  a  strenuous  life  on  account  of  his  active  business. 
An  attack  of  gall-stones,  which  was  accompanied  by  an  infection 
of  the  biliary  tract,  led  to  an  operation  on  November  15,  101"). 
Prior  to  the  operation  the  urine  was  examined  and  found  normal. 
The  anesthetic  was  ether.  Convalescence  from  the  operation  was 
satisfactory,  but  while  at  the  hospital  his  friends,  knowing  his 
fondness  for  sweets,  sent  him  much  candy,  which  lie  ate.  On 
December  11,  1015,  he  observed  polyuria,  and  later  he  recalled 
that  when  nervous  and  working  hard  this  symptom  had  occurred 
on"  and  on  for  a  day's  duration  during  several  years.  On  December 
11,  1015,  sugar  was  demonstrated  in  the  urine,  and  upon  the  fol- 
lowing day,  when  he  came  for  treatment,  the  specific  gravity  was 
1045  and  the  percentage  of  sugar  was  7.2.  Albumin  and  diacetic 
acid  were  absent,  and  the  sediment  was  negative.  The  weight 
of  the  patient  was  approximately  1S5  dressed,  shortly  after  the 
operation,  and  on  December  13  was  1(17  naked.  Physical  exami- 
nation was  negative.  The  patient  began  fasting  by  going  without 
his  supper  on  December  12,  and  the  twenty-four-hour  quantity 
of  urine  ending  December  14  contained  only  a  trace  of  sugar, 
and  even  this  was  absent  the  following  day.  Improvement  was 
uninterrupted. 

The  important  ctiological  factors  of  diabetes  were  all  present  in 
this  case.  There  was  a  tendency  to  diabetes,  as  illustrated  by  the 
death  of  his  two  children  with  the  disease;  obesity  and  dietary 
excesses  existed;  a  strenuous  life;  nervous  excitement  connected 
with  the  operation;  the  presence  of  an  infection;  the  trauma  of 
the  operation,  and  presumable  interference  with  the  normal  action 
of  the  pancreas  and  liver.  The  other  factors  which  it  is  customary 
to  consider  in  the  etiology  of  diabetes,  namely  arteriosclerosis, 
syphilis  (negative  \Vasserinann),  disease  of  the  thyroid  gland, 
acromegaly,  gout  and  Bright's  disease  were  absent. 


ETIOLOGY  OF  DIABETES  61 

It  was  interesting  that  the  disease  did  not  break  out  earlier  in 
the  case  of  this  patient,  when  one  realizes  that  obesity  had  existed 
several  years  before.  It  plainly  suggested  that  obesity  alone  was 
not  a  sufficiently  strong  factor  to  lead  to  the  disease.  Even  when 
to  this  were  added  dietary  excesses  and  the  strenuous  life,  the 
disease  still  remained  latent  and  only  a  multiplicity  of  influences, 
such  as  were  brought  about  by  the  operation,  were  sufficient  to 
make  it  declare  itself. 

4.  Heredity. — The  influence  of  heredity  has  been  elsewhere  dis- 
cussed.    (See  p.  33.) 

5.  Strenuous  Life.- — A  strenuous  life  has  been  considered  by  most 
writers  as  of  importance  in  the  etiology  of  diabetes,  and  it  has  so 
impressed  me.    Yon  Xoorden  records  that  S  per  cent,  of  all  his  mild 
diabetic  patients  were  physicians,  and  this  can  easily  be  connected 
with  the  strenuous  life  which  medical  work  entails.    The  frequency 
diabetes  among  physicians,  however,  is  undoubtedly  in  part  due  of 
to  the  opportunity  they  have  for  detecting  the  disease.     In  my 
own  series  of  male  patients,  above  the  age  of  20,  10  per  cent,  have 
been  physicians.     Of  these  15  have  died,  and  the  average  duration 
of  the  diabetes  was  seven  years ;  47  are  alive  and  the  average  duration 
of  the  diabetes  up  to  December  1,  1916,  was  likewise  seven  years. 

6.  Nervous    Element. — The   nervous   element   in   diabetes    has 
received  additional  importance  since  the  publication  of  the  work  of 
Cannon,  Shohl  and  Wright1  and  the  investigations  of  Folin,  Denis 
and  Smillie2  upon  the  appearance  of   sugar  in  the  urines  of    192 
insane  patients.    Of  these,  22  showed  sugar  with  the  standard  tests. 
The  latter  investigators  also  examined  the  urines  of  students  after 
important   examinations.      "Of   34   second-year   medical   .students 
examined  before  and  after  an  examination,   1    had    sugar    both 
before   and   after  the  examination.     Of  the  remaining  33,  6,  or 
IS  per  cent.,  had   small  but  unmistakable  traces  of  sugar  in  the 
urine  passed  immediately  after  the  examination.    A  similar  study 
was  made  on  second-year  women  students  at  Simmons  College. 
Since  these  students  were  younger  and  presumably  much  more  ex- 
citable than  our  medical  students  it  was  thought  that  even  more 
striking    results    might    be    obtained.     This    expectation    did    not 
prove  to  be  well  founded.    Out  of  36  taking  the  examination  and 
who  had  no  sugar  in  the  urine  on  the  day  before,  6,  or  17  per  cent., 
eliminated    sugar   with   the    urine    passed   immediately   after   the 
examination."    Case  Xo.  10  developed  severe  diabetes  when  on  an 
unusual  business  trip  involving  much  responsibility.     The  appear- 
ance of  polyuria  and  polydipsia  was  acute,  but  he  lived  twelve  years. 
In  comparatively  few  instances  in  this  series  was  the  presence  of  an 

1  Cannon,  Shohl  and  Wright :  Amer.  Jour.  Phyis.,  1911,  xxix,  p.  2.SO 

2  Folin,  Denis  and  Smillie:  Jour.  Biol.  Chsm.,  1914,  xvii,  p.  519. 


02  DIABETES    MKLLITl'X 

organic  nervous  disease  demonstrated.  Allen's  conception  of  the 
functional  nature  of  diabetes  shows  how  the  disease  may  be  brought 
about  through  the  nervous  system  by  its  action  upon  the  pancreas. 
Thus  the  Claude  Bernard  puncture  produced  diabetes  in  one  of 
Allen's  dogs,  predisposed  to  the  same  by  the  removal  of  a  portion 
of  the  pancreas,  and  yet  proved  to  be  non-diabetic  before  the 
puncture.  Jn  this  dog  characteristic  changes  were  found  in  the 
islands  of  Langerhans  at  autopsy. 

7.  Infections.—  The  influence  of  infections  has  received  consider- 
able attention  of  late.  In  only  a  few  instances  have  I  been  able  to 
associate  infectious  diseases  with  diabetes;  in  fact,  in  only  2S  cases 
of  my  series,  \\hen  one  considers  the  frequency  of  infectious 
diseases  in  a  community  and  the  rarity  with  which  diabetes  develops 
after  the  same,  one  is  not  inclined  to  assign  great  importance  to 
infections.  On  the  other  hand,  the  marked  lowering  in  tolerance  for 
carbohydrates  in  the  diabetic  patients  when  an  infection  appears 
is  an  emphatic  demonstration  that  this  subject  should  be  thoroughly 
investigated,  and  I  certainly  remain  open-minded  upon  it. 

My  data  do  not  show  how  important  a  part  the  teeth  and  gums 
play  in  the  etiology  of  diabetes. 

S.  Arteriosclerosis.  —  The  frequency  of  arteriosclerosis  with 
diabetes  is  perhaps  best  explained  by  the  increasing  incidence  of  the 
disease  as  age  advances. 

9.  Syphilis. — The   influence    of    syphilis    in    causing   diabetes    is 
possible,  either  directly  by  disease  of  the  pancreas,  or  indirectly 
by  its  effect  upon  the  bloodvessels,  which   in  turn  interfere  with 
the  blood  supply  of  the  gland.     Reliable  statistics  concerning  the 
relation  of  syphilis  to  diabetes  are  still  lacking.     Nineteen  cases  in 
my  series  have  given  a  history  of  syphilis,  but  such  data  are  of 
comparatively  little  value.     A  Wassermann   test   has  been   made 
upon  107  patients,  and  has  been  found  positive  in  (>  instances.     The 
last  .")()  Wassermann    tests  upon  diabetic  patients  have  all   been 
negative.     (See  p.  2(,)2.) 

10.  Trauma.-    A  definite  history  of  trauma  immediately  preced- 
ing the  disease  was  present  in  Ca*es  Xos.  7  and  !)Sl2  of  my  series. 
In  Case  No.  7  the  patient  observed  the  first  symptoms  of  diabetes 
directly  after  being  injured  by  a  cow.     He  was  seen  by  me  once  on 
October  _!.">,  1S9S,  four  weeks  later,  and  died  in  coma  five  months 
after  the  onset.     No  record  of  a  previous  urinary  examination  exists. 
Case  No.  DSL.'  was  seriously  hurt  in  his  back  in  a  foot-ball  game, 
in  the  fall  of   1  !>!:•>,  and  became  unconscious.     A  broken  neck  was 
suspected.      In  the  following  January  he  again  had  a  serious  fall  in 
the  woods  and  again  injured  his  back,  so  that  he  was  incapacitated 
for  three  weeks.     At  the  expiration  of  this  time  he  observed  that  his 
mouth  was  dry,   and   in    February  sugar  was  found   in  the  urine. 
Case  No.  954  developed  the  diabetes  after  the  trauma  of  an  operation 


ETIOLOGY  OF   DIABETES  63 

but  there  were  many  other  etiological  factors  present,  and  further- 
more such  an  event  must  be  extremely  rare. 

Case  No.  11SS  probably  represents  best  of  all  the  indirect  harm 
which  may  result  from  trauma,  though  his  case  resembles  most 
cases  of  the  supposed  influence  of  trauma  upon  diabetes  by  lack  of 
evidence  showing  its  absence  before  the  accident.  Case  Xo.  11S8 
was  an  ice-cream  manufacturer  in  1915,  at  the  age  of  thirty-one, 
weight  242  pounds.  He  was  in  the  habit  of  eating,  in  addition  to 
his  regular  meals,  two  quarts  of  his  own  ice-cream.  During  the 
subsequent  year,  his  weight  fell  to  about  212  pounds,  when  on 
October  27,  he  was  accidentally  shot  with  a  rifle,  and  his  leg  badly 
shattered,  requiring  frequent  painful  dressings.  The  urine  was 
first  examined  on  November  27,  19 1C),  and  sugar  found.  The 
quantity  amounted  to  37SO  c.c.,  and  the  percentage  of  sugar  was 
large.  Under  treatment  he  gradually  became  sugar-free  and  acquired 
a  tolerance  for  about  SO  grains  carbohydrate. 

The  fracture  of  an  extremity  is  often  accompanied  by  glycosuria. 
Among  (>1  cases  at  the  Surgical  Clinic  at  Kiel,  24  showed  alimentary 
glycosuria,  and  in  3  unsuspected  diabetes  was  discovered.  Hyper- 
glycemia  was  present  in  31  out  of  3(>  of  the  cases  examined.1  It 
would  not  seem  strange  if  many  of  the  cases  of  diabetes  following 
trauma  might  be  due  to  the  enforced  idleness  and  rest  combined  with 
forced  feeding  at  the  hands  of  friends. 

11.  Pancreas. — Disturbance  in  the  physiological  action  of  the 
pancreas  or  disease  of  the  gland  is  a  basal  etiological  factor  which 
all  recognize  to  exist  in  diabetes.    I  await  with  interest  the  results 
of  the  experimental  observations  of  Allen  upon  the  gland  and  his 
summary  of  the  literature,  and  believe  it  far  better  to  refer  the 
reader  to  his  report,  which  will  surely  be  included  in  his  forthcoming 
publication. 

12.  Hypophysis. — The  intimate  relation   of  the  hypophysis  to 
glycosuria  and  diabetes  has  been  emphasized  by  dishing,  and  is 
described  in  detail  by  him.2 

I.'].  Liver. — The  connection  between  diseases  of  the  liver  and 
diabetes  has  been  frequently  pointed  out.  Such  an  association  is 
not  easily  demonstrable  in  my  cases,  for  out  of  51(5  cases  there  have 
been  only  3  who  have  died  in  which  cirrhosis  of  the  liver  appeared 
to  figure  as  a  cause  of  death,  and  but  7  of  cancer  of  the  liver.  The 
interesting  series  of  20  cases  (Table  140,  p.  295)  in  which  gall-stones 
have  been  a  factor  probably  should  be  credited  etiologically  to  the 
pancreas. 

14.  Renal  Glycosuria. — Glycosuria  with  normal  glycemia  rela- 
tively independent  of  diet.  In  other  words,  the  excretion  of  sugar 
must  be  due  to  abnormal  permeability  of  the  kidney,  while  the 

1  Konjetzuy  and  Wetland:    Jour.  Am.  Med.  Assn.,  1915,  Ixv,   p.  2264. 

2  Gushing:  The  Pituitary  Body  and  its  Disorders,  Philadelphia,  1912. 


04  DIABETES  MELLITUS 

tissues  still  retain  the  normal  power  of  utilizing  dextrose.1  A 
diagnosis  of  renal  diabetes  should  be  very  cautiously  made.  Most 
of  the  cases  in  the  literature  have  been  observed  for  short  periods. 
No  eases  have  been  proven  congenital  and  few  eases  have  had  blood- 
sugar  examinations  extending  over  a  period  of  years.  Bonninger's 
case2  was  observed  for  six  years.  The  glycosuria  is  seldom  absolutely 
independent  of  the  diet.  Theoretically,  the  renal  diabetes  might 
be  of  a  severe  type,  as  described  by  Gallambos,3  or  of  a  mild  type, 
according  to  the  depression  of  the  sugar  threshold.  Lewis  and 
Mosenthal's  case4  was  carefully  studied  and  exhibited  some  evidences 
of  depression  of  renal  function,  as  disclosed  by  a  slightly  diminished 
phenolsulphonephthalein  excretion,  and  a  slightly  elevated  Ambard's 
reaction.  Murlin  and  Nilesr'  report  another  instance  in  which 
throughout  a  period  of  nineteen  days  the  blood  sugar  varied  between 
O.OcS  and  0.105  per  cent.,  the  sugar  in  the  urine  between  19  and  34 
grams  and  the  carbohydrate  in  the  diet  between  15  and  100  grams. 
Strauss0  describes  the  case  of  a  boy,  aged  thirteen  years,  whose 
urine  contained  a  non-quantitatable  percentage  of  sugar  for  three 
weeks  on  a  non-carbohydrate  diet,  but  one  hour  after  a  meal  rich 
in  carbohydrate  showed  0.04  per  cent,  sugar. 

Clinically,  it  is  dangerous  to  make  a  diagnosis  of  renal  diabetes 
until  the  patient  has  been  under  observation  for  several  years. 
Among  my  cases  of  diabetes  of  a  duration  of  fifteen  years  some  may 
belong  to  this  group  (see  p.  4(iS).  Unfortunately  all  the  recent 
cases  of  renal  glycosuria,  so  carefully  worked  up,  have  been  observed 
for  very  short  periods.  A  duty  rests  upon  all  physicians  who 
report  such  cases  to  describe  their  future  course.  (See  page  29()  for 
Miller's  and  my  own  experience  in  reporting  the  disappearance 
of  sugar  after  removal  of  a  fibroid  tumor  of  the  uterus.) 

15.  Gout.  —  Gout  is  frequently  mentioned  as  a  precursor  or 
companion  of  diabetes.  So  seldom  has  this  occurred  in  my  experi- 
ence; that  I  cannot  attach  much  importance  to  it.  Dr.  J.  II.  Pratt, 
of  Boston,  who  has  seen  an  unusually  large  number  of  cases  of  gout, 
and  has  a  series  of  '.>()  cases  of  chemically  proven  gout,  assures  me 
that  in  no  instance  was  sugar  found  in  the  urines  of  his  patients. 

H.     CAUSES  OF  DEATH  IN  DIABETIC  PATIENTS. 

The  end-results  of  all  the  11X7  diabetic  patients  whom  I  have 
seen  in  private  practice  from  1X94  to  December  1,  191G,  have  been 

1  Allen:    Lor.  cit.,  p.  .">  1  1. 

2  Bonniimcr:    Verb.  d.  Cunt:,  f.  Inn.  Mod.,  lOl.'i,  xxx,  p.  17<s. 
Hlallamhos:  Dent.  Mod.  Wurh.,   101  1,  xl.  p.   KiOl. 

4  Lewis  and  Mosontbal:    Bulletin  .lobns  Hopkins  Hospital,  101  fi,  xxvii,  p.  544. 

5  Murlin  and  Xiles:  American  Journal  of  Medic. il  Sciences,  1017,  rliii,  p.  70. 
c  Strauss:  Chicago  Medical  Clinics,  1010,  ii,  p.  .'WO. 


CAUSES  OF  DEATH  7.V   DIABETIC  PATIENTS  05 

sought.  Of  these  11S7  cases,  97.4  per  cent,  have  been  traced,  and 
out  of  this  number  51()  have  died.  The  actual  causes  of  death  are 
known  to  me  in  all  but  1 0  cases.  It  is  true  that  many  of  the  patients 
were  seen  by  me  but  once,  yet  this  by  no  means  detracts  from  their 
interest. 

During  the  year  ending  December  1,  1910,  241  new  cases  of 
diabetes  were  added  to  the  records  and  129  old  cases  returned  for 
treatment,  making  a  total  of  370  cases  seen  during  the  twelve 
months.  Of  this  number  38,  or  10.3  per  cent.  died.  Of  these  25 
were  new  cases,  making  a  mortality  for  the  new  cases  of  10.4  per  cent. 
and  13  were  old  cases,  making  a  mortality  for  the  old  patients  seen 
during  the  year  of  10  per  cent.  Thirty-nine  cases  seen  in  preceding 
years  also  died  during  the  year,  or  12.1  per  cent,  of  the  living  old 
cases  who  were  not  seen.  A  few  cases,  15,  were  also  discovered  to 
have  died  in  previous  years,  of  whose  death  we  had  no  record,  and 
these  had  previously  been  classed  as  untraced. 

Nine  of  the  patients  seen  during  the  year  died  in  hospitals, 
17  others  had  been  treated  in  hospitals  during  the  year  and 
died  after  their  discharge;  the  remaining  12  deaths  were  among 
patients  seen  either  at  the  office  or  in  consultation.  These  38  cases 
who  died  this  last  year  will  be  discussed  in  detail  elsewhere 
(see  ]>.  330),  because  these  are  the  cases  from  whom  lessons 
for  the  improvement  in  the  treatment  of  diabetes  can  be 
learned.  In  fact,  it  is  on  account  of  these  38  deaths  that  I  justify 
myself  in  taking  the  time  and  going  to  the  expense  of  maintaining 
my  statistics. 

Forty-six  of  the  fatal  cases  were  among  males.  This  constitutes 
0.0  per  cent,  of  the  total  males  traced.  Thirty  of  the  deaths  were 
among  females,  or  0.5  per  cent,  of  the  females  traced. 

Coma  was  the  cause  of  death  of  04  per  cent,  of  all  the  cases  when 
the  statistics  were  collected  up  to  November  18,  1915;  but  now 
(December  1,  1910)  the  percentage  has  fallen  to  00  per  cent.  In  no 
other  way  will  improvement  in  treatment  show  more  strongly  than 
in  the  gradual  decrease  of  this  percentage.  A  death  by  coma  in 
diabetes  is  like  a  death  by  perforation  in  duodenal  ulcer — a  death 
to  be  prevented.  Consequently  a  decrease  in  the  percentage  of 
deaths  in  diabetes  by  coma  speaks  well  for  the  change  in  treatment. 

A  new  cause  of  death  appears  this  year  in  the  mortality  tables, 
and  it, may  increase  as  a  factor,  but  I  hope  for  only  a  few  years  to 
come.  This  is  inanition,  and  to  it  three  deaths  must  be  credited. 
Otherwise,  save  for  numerical  changes  in  the  individual  causes,  the 
table-  remains  the  same. 

1 .  Deaths  without  Coma. — The  causes  of  death  of  these  patients 
will  be  discussed  under  six  headings, ,  into  the  first  of  which  I  will 
place  the  miscellaneous  and  uncommon  cases. 


i  DIABETES   MELLITUS 

TABLE    44. — CAUSES   OF    DEATH    OF   FIVE    HUNDRED  AND   SIXTEEN 

DIABETIC   PATIENTS  SEEN  IN   PRIVATE   PRACTICE  <)\E  OR  MOKE 

TIMES  FROM    1X94  TO  DECEMBER  18,  1915,  COMPARED  WITH 

SIMILAR  DATA  EXTENDING  TO  DECEMBER   11,    1910. 

DEATHS  WITHOUT  COMA:  To  Doc  is,     To  Doc 

1.   Miscellaneous:  icir,.  line,. 

Pernicious  anemia 1  1 

Cirrhosis 2  3 

Oldajie 2  2 

Suicide 2  2 

Drowned 1  1 

Diabetes 8  11 

Cause  unknown (i  10 

Total  miscellaneous 22  30 

II.  Cancer: 

Breast        1 

Face 1  1 

Esophagus 1  1 

Stomach 4  6 

Intestine 1 

Kectum 1  1 

Liver 6  fl 

Kidney      1 

Bladder 2  3 

Bones  (sarcoma) 1  1 

Location  unknown 1  1 

Total  cancer 17  23 

111.  Tuberculosis: 

Pulmonary 1(1  17 

Peritoneal       .             .  1 

Meningeal 1 

Total  tuberculosis Ill  19 

IV.  Carcliorenal  and  vascular: 

Cardiac .28  34 

Chronic  nephritis      .           14  lo 

Cerebral  hemorrhage       ...'...             .14  20 

Arteriosclerosis 6  ('> 

Pulmonary  edema .         .  1 

Knlariied  prostate      ....             2 

Total  cardiorenal  and  vascular,  renal  and  pros- 
tat  ic          (12  7S 

V.   Infections: 

Pneumonia      .                                                                 .       !">  22 

Influenza  .             .3  3 

Tonsillitis        .                    ...             ....         1  1 

Krysipelas       .             .1  1 

(iu'll-stones      ....                   ...             .1  1 

Acute  appendicit  is     .                                 ...        2  ~> 

( 'urbuncle ....         1  ."> 

Acute  abdominal 2 

Abscess,  iun>r 1 

Sepsis  or  fiangrene  of  lower  extremities     .      .             9  14 


Total  infections 

VI .   Inanition o 

DEATII>  WITH  COMA       ........  .    27:!  30S 

or  or 

64  per  cent.  60  per  cent. 


CAUSES  OF  DEATH   IX  DIABETIC   PAT  I  EXT  8  07 

(a)  Miscellaneous. —  In  this  group  fall  1  death  of  pernicious 
anemia,  3  of  cirrhosis  of  the  liver,  2  of  old  age  (ages  seventy-eight 
and  eighty-six  years),  11  eases  of  whom  1  can  secure  no  other  details 
than  a  death  report  signed  diabetes,  as  well  as  10  who  died  of  causes 
unknown  to  me.  The  small  number  of  deaths  from  cirrhosis  always 
appears  remarkable.  One  patient  was  drowned  and  2  committed 
suicide.  Of  the  latter,  one  was  mentally  unbalanced,  and  the  latter 
took  her  life  after  becoming  pregnant  a  second  time  soon  after  an 
abortion.  Today  I  should  not  advise  an  abortion  unless  vigorous 
and  prolonged  treatment  failed  to  render  the  urine  sugar-  and  acid- 
free.  Xo  patient  has  died  as  a  result  of  pregnancy  since  this  patient 
took  her  life  in  October,  1014. 

(6)  Cancer. — Twenty-three  of  the  patients  died  of  cancer.  The 
primary  growths  were  in  the  breast,  face,  esophagus,  stomach, 
intestines,  rectum,  liver,  kidney,  bladder,  and  I  include  1  case  of 
probable  sarcoma  of  the  pelvic  bones.  The  average  age  at  death 
of  these  patients  was  sixty-five  years  and  four  months.  Cancer 
apparently  developed  after  the  diabetes  in  15  cases,  and  may 
have  developed  before  or  coincident  with  the  diabetes  in  8  others. 
Incidentally,  I  would  say  that  2  cases- of  cancer  which  have  been 
operated  upon  are  alive.  I  of  the  uterus.  Case  Xo.  799,  and  1  of 
the  breast,  Case  Xo.  1088.  Of  two  patients  with  cancer  of  the 
bladder  one  died  suddenly  of  pulmonary  embolism,  nine  days  after 
its  removal  and  the  other  with  recurrence  in  the  abdominal  scar. 

(('}  Tuberculosis. — Pulmonary  tuberculosis  was  responsible  for 
the  death  of  17  cases,  thus  adding  but  one  death  to  those  of  a 
year  ago.  This  is  significant,  for  so  far  the  predictions  which 
followed  the  introduction  of  the  fasting  treatment  have  not  been 
fulfilled.  Those  gentlemen  who  saw  tuberculosis  in  every  fasting 
diabetic,  forgot  that  fasting  simply  ushered  in  the  new  diabetic 
campaign  for  life.  The  medical  profession  has  altogether  too  pessi- 
mistic a  view  about  this  complication.  \Yhen  the  treatment  of  the 
diabetes  is  faithfully  carried  out.  these  patients  do  quite  well.  The 
trouble  in  the  past  has  been  that  consumption  was  usually  advanced 
when  diagnosed.  In  a  diabetic,  temperature,  pulse  and  respiration, 
may  give  no  clue  to  the  diagnosis,  and  the  loss  of  weight  is  attributed 
to  the  diabetes.  One  patient  died  of  meningeal  tuberculosis,  the 
pulmonary  symptoms  having  subsided  in  large  measure  and  another 
of  tuberculosis  of  the  peritoneum. 

(d)  Cardiorenal  and  Vascular. —  Cardiorenal  and  vascular  changes, 
uncomplicated  by  coma,  caused  the  death  of  78  cases.  Of  these,  34 
died  of  heart  disease,  in  four  instances  suddenly  with  angina  pec- 
toris;  15  died  of  chronic  nephritis;  20  from  a  cerebral  hemorrhage; 
G  of  general  arteriosclerosis.  The  average  age  at  death  of  these 
patients  was  sixty-four  years.  If  the  methods  we  employ  in  the 


OX  DIABETES  MELLITVS 

treatment  of  these  same  arteriosclerotic  conditions  in  non-diabetic 
patients  are  correct,  it  is  difficult  to  see  how  modern  treatment  with 
restricted  instead  of  forced  feeding  can  fail  to  prolong  the  life  of  these 
individuals.  Two  of  the  patients  succumbed  to  an  enlarged  prostate. 

(c)  Infections. — 1  he  advent  of  an  infection  lowers  the  tolerance 
of  a  diabetic  for  carbohydrate  and  thus  increases  the  severity  of  the 
disease.  This  is  an  old  and  reliable  clinical  fact.  It  has  lately 
been  emphasized  by  the  Chicago  School.1  Case  No.  cS13,  aged  eight 
years,  sugar-free  for  eighteen  days,  developed  tonsillitis  and  with- 
out change  of  diet  a  positive  carbohydrate  balance  of  50  grams 
dropped  to  14  grams,  with  reappearance  of  acidosis.  Recent 
experiences  with  fasting  treatment  show  that  in  the  presence  of  an 
infection  a  diabetic  becomes  sugar-free  very  slowly,  and  if  sugar- 
free,  sugar  may  return.  An  infection  is  an  additional  load  for  the 
diabetic  to  carry  and  to  it  he  often  succumbs.  If  those  cases  are 
excluded  in  which  coma  was  an  element,  the  number  of  deaths  from 
infections  is  comparatively  small,  for  there  were  but  of).  This  is  a 
distinct  increase  over  my  figures  of  a  year  ago.  It  is  quite  possible, 
indeed  probable,  that  acidosis  existed  in  company  with  the  infection, 
but  the  infection  appeared  so  much  more  important  that  it  was 
disregarded  or  overlooked  as  a  cause  of  death.  Fortunately,  most 
patients,  no  matter  what  the  disease,  are  unconscious  when  they  die 
and  if  coma  did  occur  in  this  group  it  was  not  attributed  to  diabetes., 
The  point  is  a  hard  one  to  decide,  and  too  much  weight  must  not  be 
put  upon  statistics. 

Of  general  infections,  pneumonia  heads  the  list  with  22  deaths, 
influenza  claims  )>,  and  tonsillitis  and  erysipelas  each  1.  A  con- 
siderable number  of  patients  have  passed  through  pneumonia  suc- 
cessfully, e.  </.,  ( 'ases  Nos.  S,  11),  :;(>,  4(>,  .V>S,  4ii5,  Si)")  and  1274.  Of 
local  infections,  septic  and  gangrenous  legs  account  for  14,  car- 
buncles for  f>,  and  acute  fulminating  appendicitis  for  f>  deaths. 
Coma  was  a  terminal  event  in  some  of  the  cases  of  appendicitis, 
though  the  abdominal  condition  appeared  to  be  sufficiently  severe 
without  it  to  cause  a  fatal  issue.  One  patient  died  of  gall-stones 
without  coma.  Two  died  of  acute  abdominal  infections  and  of 
these  the  physician  thought  pancreatitis  probable  in  one.  One 
patient  died  of  an  abscess  of  the  lung. 

(/)  Inanition. — The  three  deaths  of  inanition  were  the  first  of  this 
character  in  diabetes  which  I  remember  to  have  seen  in  twenty-three 
years.  The  later  symptoms  of  these  patients  were  painless,  the  weak- 
ness was  by  no  means  overpowering,  and  the  same  tendency  to 
hopefulness  was  exhibited  by  the  one  adult,  Case  Xo.  1085,  which  is 
so  frequently  seen  in  the  consumptive.  These  three  cases  all  showed 

1  Wondyatt :  Abstract  Proc.  Seventh  Annual  Meeting  Am.  Hoc.  Advancement 
Clin.  Invest.,  1'Jl.J,  p.  25. 


CAUSES  OF  DEATH   IN   DIABETIC   PATIENTS  69 

acid  poisoning  at  one  time  or  another.  One,  Case  No.  785,  died 
eleven  months  after  leaving  the  hospital;  one,  Case  No.  1120,  died 
in  the  hospital,  and  his  case  is  described  on  page  338,  and  the  third 
case,  Case  Xo.  1085, died  six  days  after  discharge.  In  each  case  an 
attempt  was  made  to  increase  the  protein  and  fat  in  the  diet,  and 
in  each  case  it  was  evident  to  the  relatives  as  well  as  to  us  that  if 
this  increase  was  maintained  acidosis  would  continue  to  increase 
and  death  would  follow.  Two  of  these  patients  died  sugar-  and 
acid-free,  but  1  do  not  know  the  details  of  the  remaining  case. 
The  one  change  which  1  should  make  in  the  treatment  under  similar 
circumstances  would  be  to  fast  more  rigorously  the  first  few  days, 
hoping  thereby  to  be  able  to  increase  more  rapidly  the  calories  in 
the  diet  in  the  subsequent  days. 

Thus  2CS  deaths  are  explained.  Of  this  number  a  good  many 
could  be  saved  today.  One  death  from  suicide  almost  certainly 
could  have  been  prevented;  tuberculosis  could  be  earlier  diagnosed, 
or  better,  by  prophylaxis  its  development  prevented,  and  even  if 
it  did  occur,  treatment  would  certainly  today  accomplish  much 
more  than  formerly;  likewise,  present-day  methods,  I  am  convinced, 
will  accomplish  much  in  prolonging  the  lives  of  the  cardiorenal 
group.  Our  better  knowledge  of  the  disease  cannot  but  help  in  the 
presence  of  an  infection,  especially  when  caused  by  local  sepsis. 

2.  Deaths  with  Coma. — Coma  was  the  cause  of  308,  or  60  per  cent. , 
of  the  deaths.  1  Hiring  the  last  fifteen  years  there  have  been  treated 
under  my  personal  supervision  in  hospitals  406  cases  of  diabetes,  of 
whom  21  have  died  of  coma,  making  the  total  deaths  in  hospitals 
for  this  period  26.  For  many  years  my  attitude  toward  coma  was 
to  consider  it  the  culmination  of  the  diabetes,  and  after  the  death 
of  the  comatose  patient  I  could  honestly  unite  with  the  family,  the 
physician  and  the  nurse  in  the  feeling  that  no  more  could  have  been 
done.  But  for  me  this  comfortable  creed  has  passed,  and  in  its 
place  has  come  the  opinion  that  coma  by  no  means  represents  the 
culmination  of  the  disease,  that  it  is  not  a  justifiable  accident, 
and,  though  not  in  all,  yet  in  most  cases,  it  is  avoidable.  My 
conception  of  coma  in  diabetes  cannot  better  be  expressed  than  by 
quoting  from  the  valuable  essay  of  Moynihan1  on  "Inaugural 
Symptoms"  in  abdominal  emergencies  with  especial  reference  to 
duodenal  ulcer,  only  changing  the  word  "ulcer"  and  the  phrase 
"in  the  abdomen"  to  "diabetes,"  and  the  word  "perforation"  to 
"coma." 

With  the  wording  thus  changed  the  text  would  read:  "It  is  in 
dealing  with  the  acute  catastrophes  occurring  in  diabetes  that  we 
shall  probably  derive  the  most  instant  and  striking  advantage  from 

1  Moynihan:  The  Pathology  of  the  Living  and  Other  Essays,  Philadelphia,  1910. 


70  DIABETES   ME1JJTUS 

an  attentive  study  of  inaugural  symptoms.  .  .  .  To  take  a 
specific  example,  the  onset  of  cnina  in  ditilu'lcx.  But  let  me  first  say 
that  a  catastrophe  of  this  kind  is  almost  always  capable  of  being 
forestalled.  Though  the  onset  of  count  in  dinl/ctcx  is  acute,  the 
didlx'trx  itself  is  chronic.  It  is  a  disease  that  has  existed  for  months 
or  years,  and  it  has  given  in  almost  every  instance,  not  only  sustained 
evidence  of  its  existence,  but  a  recent  warning  that  the  pathological 
processes  engaged  in  it  were  becoming  more  acute.  The  warning, 
however,  is  commonly  ignored,  because  the  significance  and  impor- 
tance1 of  it  are  not  understood,  and  accordingly  a  disaster  is  precipi- 
tated. There  are  few  catastrophes  occurring  in  diabetic  that  are 
veritably  acute." 

bearing  this  point  of  view  in  mind,  the  deaths  from  coma  which 
have  occurred  in  my  practice  in  hospitals  will  be  analyzed  and  at 
the  same  time  reference  will  be  made  to  those  patients  dying  else- 
where, whose  history  was  of  especial  significance.  (See  also  Table 
154,  p.  :mj 

(d)  Ether  Anesthesia.  —  Case  Xo.  720,  a  severe  diabetic,  three 
months  after  her  last  visit  to  me,  without  my  knowledge,  was  taken 
to  a  dentist's  office,  given  ether  by  her  physician,  and  all  her  teeth 
extracted.  This  was  on  a  Monday.  She  was  taken  home,  became 
unconscious  Wednesday,  and  died  on  Friday.  It  is  hard  to  believe 
that  her  death  represented  the  culmination  of  diabetes,  or  was  even 
accidental.  Case  Xo.  34X,  before  an  operation  for  removal  of  a 
prostate,  was  free  from  acid  and  sugar  and  tolerated  20  grams  of 
carbohydrate.  After  light  etherization  followed  by  three  days' 
fasting,  ;>:>  and  41  grants  of  sugar  appeared  in  the  urine  on  the 
second  and  third  days  respectively,  and  the  ammonia  was  )•).)•> 
grams.  It  is  true  that  he  recovered,  just  as  all  but  7  of  H4  patients 
undergoing  major  operations  have  also  done,  but  the  ether  lowered 
his  tolerance  and  made1  his  diabetes  temporarily  worse.  This 
does  not  mean  that  diabetics  should  not  be  operated  upon,  but  it 
demonstrates  that  ether  anesthesia  is  a  burden  which  a  light  case1 
of  diabetes  may  easily  be-ar,  which  may  change  a  mode-rate1  to  a 
severe  case1,  and  to  a  severe  case1  may  be  fatal. 

(b)  Impaired  Kidneys. — IHabetic  patients  with  vulnerable  kidneys 
are1  peculiarly  suse-eptible  te>  coma  because  the  power  of  elimination 
of  acid  bodies  is  impaired.  Many  will  re-call  cases  ot  Bright's 
disease1  in  diabetes  in  which  an  apparently  mild  acidosis  preceded 
coma.  Years  ago  (Joodall1  and  I  pointed  out  that  acidosis  was 
miie-h  more  ivadily  tolerated  by  the  young  than  the  old  diabetics, 
and  this  e-tn  we'll  be1  attributed  to  the1  deficient  kidne'vs  of  the1  latter. 
Few  could  void  on  the1  verge  of  coma  the  .">  or  more1  liters  of  urine 
which  with  the1  old  alkaline1  treatment  was  ncerssary  tor  ive-overy, 

1  (loud;, 11     and     .lo.-lin:     The   Clinical    Value   of     the 
Diabetes,   Boston   Med.   and  Sun:.  Jour.,    l!H).x,  clviii, 


CAUSES  OF  DEATH  IN  DIABETIC  PATIENTS  71 

and  is  recorded  to  have  taken  place  in  most  patients  who  did  recover. 
Coma  by  no  means  is  exceptional  in  the  old;  thus  the  percentage 
of  coma  in  my  fatal  cases  under  fifty-one  years  was  07  per  cent., 
but  above  that  age  33  per  cent.  A  good  many  instances  of  this 
type  could  be  specified,  and  in  this  group  might  well  be  classed  a 
fe\v  of  the  cases  of  death  in  pregnant  women. 

(c)  Infections. — Already  attention  has  been  called  to  the  fact  that 
an  infectious  process  renders  the  diabetes  more  severe.  A  con- 
siderable percentage  of  the  cases  of  coma  occurred  in  connection 
with  either  general  or  local  infectious  processes.  It  not  infrequently 
happens  that  the  infection  is  not  recognized.  Better  statistics 
upon  this  point  and  in  general  about  the  circumstances  attending 
coma  should  be  accumulated.  Thus,  Case  Xo.  830,  seen  in  con- 
sultation one  evening,  was  found  to  be  in  partial  coma,  but  1  was 
able  to  demonstrate  to  the  physician  a  membrane  in  the  throat, 
and  three  hours  after  the  patient's  death  the  following  morning, 
the  Board  of  Health  reported  a  positive  culture  for  diphtheria. 

But  what  I  consider  of  far  more  importance  is  the  number  of 
procrastinating  cases  of  mild  infections  in  mild  diabetics,  chiefly  in 
their  lower  extremities,  which  frequently  prove  fatal.  The  youngest 
case  save  one  of  sepsis  or  gangrene  of  the  legs  in  a  diabetic  in  my  per- 
sonal experience  has  been  fifty  years  of  age.  In  other  words,  these 
conditions  develop  at  a  time  of  life  when  diabetes  is  mild,  and  why 
should  they  so  frequently  be  fatal?  Please  consider  with  what 
these  mild  cases  of  diabetes  have  to  contend.  Handicapped  by 
a  lingering  infection,  which  only  too  often  is  allowed  to  continue 
for  months,  with  kidneys  less  efficient  for  throwing  off  the  acidosis 
attack,  deprived  of  exercise — that  recently  proven  stimulus  to 
sugar  consumption — for  whoever  heard  of  a  poor  old  gangrenous 
diabetic  taking  exercise — these  pitiful  patients  frequently  meet 
a  fourth  enemy  in  ether  anesthesia.  Is  it  any  wonder  that  a  for- 
n.erly  innocent  disease  becomes  virulent  and  the  victim  dies  of 
coma?  There  is  no  doubt  in  my  mind  but  that  if  such  cases  had 
been  treated  vigorously,  even  with  the  dietetic  methods  of  a  few 
years  ago,  a  large  percentage  of  the  legs  amputated  might  have 
been  saved.  In  fact,  Dr.  Stetten1  has  most  ably  demonstrated 
this.  If  one  will  read  his  paper  it  will  be  seen  that  his  success  in 
these  2  cases  was  due  to  two  factors:  (1)  that  his  patients  were 
given  the  very  best  medical  treatment  of  the  time,  and  (2)  that 
they  had  the  advantage  of  expert  surgical  care.  All  are  very  well 
aware  that  if  a  diabetic  patient  has  gall-stones  to  be  removed  he 
instantly  commands  the  services  of  the  leading  surgeon  on  the 
senior  staff,  but  if  a  diabetic  patient  has  a  sore  toe  there  is  no  house 
officer  too  young  to  dress  it,  until  a  few  weeks  later,  if  the  patient 

1  Stetteu:.Tour.  Am.  Mecl.  Assn.,  1913,  Ix,  p.  112G. 


72  DIABETES  MKLLITUS 

survives  that  long,  the  surgeon  in  tlie  amphitheatre  amputates  the 
thigh.  Any  success  that  I  have  had  with  surgical  patients  in 
diabetes  has  been  due  to  the  fact  that  J  know  no  surgery,  and 
learned  that  never-to-be-forgotten  lesson  twenty-one  years  ago; 
and  further,  that  no  matter  how  trivial  the  ailment  1  have  secured 
the  very  best  surgical  skill  for  my  patients. 

(i7)  Mental  Excitement. —  An  occasional  case  of  coma  is  precipi- 
tated in  a  severe  diabetic  by  mental  excitement.  A  violent  n't  of 
anger  in  one  of  the  hospital  patients,  already  in  a  precarious  con- 
dition, was  accompanied  by  vomiting  and  inability  to  retain  liquids. 
Coma  soon  appeared,  and  this  case  1  know  to  have  been  duplicated 
by  another  outside  the  hospital.  A  patient  with  exophthalmic 
goitre  went  into  coma  with  far  more  ease  than  is  the  rule. 

(/')  The  Influence  of  a  Fat-protein  Diet. — The  explanations  of  coma 
thus  far  given  account  for  many  deaths,  but  by  no  means  for  the 
majority  of  deaths  from  coma  in  diabetes.  In  these  fourteen 
years  at  the  hospital,  9  cases  of  coma  have  occurred  under  my 
care  which  could  not  thus  be  explained.  It  is  easy  to  say  that  the 
patients  die  soon  after  admission,  but  I  cannot  get  around  the 
thought  that  if  a  patient  reaches  the  hospital  alive  1  am  responsible 
for  his  departure  from  the  hospital  alive,  too.  I  will  partly  excuse 
myself  for  the  death  of  1  patient  five  hours  after  entrance  and  for 
a  child,  aged  two  years,  who  was  in  coma  within  ten  hours,  but  I 
will  not  plead  any  excuse  for  the  other  7  deaths.  A  study  of  these 
patients  shows  none  of  the  factors  hitherto  mentioned  as  predisposing 
to  coma,  but  there  is  one  factor  which  is  common  to  all,  namely,  the 
diet  consisted  largely  of  fat  and  protein  with  little  carbohydrate, 
or  just  prior  to  entrance  or  after  entrance  an  excessive  quantity 
of  fat  had  been  given.  Diabetic  patients  will  live  untreated  for 
many  years  without  the  appearance  of  coma.  They  suffer  from 
complication  after  complication.  They  are  tormented  with  sepsis, 
neuritic  pains  and  pruritus;  yet  they  still  live.  Their  diet  is 
atrocious.  Along  conies  an  enthusiastic  young  doctor,  and  imme- 
diately fat  is  increased,  carbohydrate  diminished,  and  the  patient 
goes  into  coma.  Out  of  carbohydrates  it  is  impossible  to  form  the 
acid  bodies.  When,  therefore,  carbohydrate  is  suddenly  replaced 
with  fat,  we  deliberately  furnish  our  diabetic  patients  with  material 
which  though  it  acts  partly  as  a  food,  acts  far  more  as  a  poison. 
At  a  recent  meeting  in  New  York  upon  acidosis  in  children,  Dr. 
.lacobi  struck  the  keynote.  lie  said  that  prevention  is  the  treat- 
ment of  acidosis  in  children,  and  that  those  susceptible  to  acidosis 
ought  not  to  have  fat.  \Vhat  he  said  for  children  holds  for  diabetics. 
Diabetic  patients  need  fat;  it  forms  the  chief  constituent  of  their 
diet;  but  they  must  not  be  poisoned  with  it,  they  must  be  gradually 
accustomed  to  it. 


CAUSES  OF  DEATH  IN  DIABETIC   PATIENTS  73 

The  treatment  of  acidosis  in  the  past  has  been  unsatisfactory. 
Like  typhoid  fever,  it  should  be  prevented — not  treated,  and  in 
uncomplicated  cases  this  can  be  done.  Although  most  of  our 
diabetic  patients  will  quickly  and  safely  become  sugar-free  by 
simple  fasting,  for  the  cases  already  showing  acid  poisoning,  cases 
of  long  duration,  elderly  patients  and  diabetics  with  infections, 
I  believe  that  prior  to  giving  any  fasting  treatment  a  possible 
severe  acidosis  may  be  anticipated  by  taking  away  the  causes — 
namely,  by  the  absolute  exclusion  of  fat  from  the  diet,  without 
otherwise  changing  the  diet  or  the  habits  of  the  patient.  After  two 
days,  or  longer  if  desired,  omit  protein — another,  though  lesser 
contributing  factor  to  acidosis — and  thereafter  daily  halve  the 
carbohydrate,  hitherto  unchanged  in  the  diet,  until  10  grams  are 
reached,  and  then  proceed  with  routine  fasting  treatment  if,  as 
seldom  happens,  the  patient  continues  to  show  sugar. 

(/)  Rapid  Loss  of  Body  Fluid. — Vomiting  at  the  onset  of  coma 
usually  presages  death  because  the  patient  is  deprived  of  fluid  with 
which  to  eliminate  acids.  Body  liquids  are  so  needed  that  the 
body  in  the  course  of  coma  becomes  obviously  dry.  This  is  really 
only  another  sign  of  defective  elimination. 

For  many  years  my  interest  has  been  aroused  to  the  necessity 
of  salt  for  a  diabetic.  Recently,  too,  my  attention  was  drawn 
by  a  patient  to  the  fact  that  he  lost  13  pounds  during  the  first 
four  days  of  fasting  treatment.  Inquiry  developed  that  he  was 
only  given,  during  this  period,  water  and  alcohol.  Had  he  been 
given  broths  or  some  mineral  water,  suffice  it  to  say  that  during 
fasting,  even  for  a  week,  he  would  probably  have  lost  little  or  no 
weight.  This  is  important  because  patients  prior  to  coma  frequently 
lose  weight  rapidly.  Thus,  in  the  presence  of  multiple  carbuncles 
and  septicemia  one  of  my  patients  lost  35  pounds  in  eleven  days 
preceding  his  death.  (See  Case  No.  513.)  Years  ago  in  seeking  for 
the  cause  of  edema  in  a  severe  diabetic  patient  who  was  taking 
sodium  bicarbonate  I  withdrew  sodium  chloride  from  his  diet. 
Prompt  loss  of  weight  followed  and  symptoms  of  coma  appeared. 
(See  Case  Xo.  135,  page  127.)  Since  then  I  have  been  careful  not 
to  restrict  salt  and  I  can  well  understand  the  opinion  of  Hodgson1 
that  water,  rich  in  salts,  is  really  helpful  to  diabetic  patients. 

'Hudson:. Jour.  Am.  Med.  Assn.,  1011,  Ivii,  p.  1187. 


SECTION  IF. 


IMPORTANT   FACTORS   IX   THE  TREATMENT  OF 
DIABETES  MELU1TS. 

Xo  disease  demands  a  knowledge  of  its  pathological  physiology 
for  successful  treatment  more  than  diabetes  mellitus;  with  such 
knowledge  treatment  is  almost  self-evident.  For  this  reason  I  will 
discuss  various  aspects  of  its  pathological  physiology  as  well  as  cer- 
tain conceptions  of  the  disease,  namely,  those  of  Xaunyn  and  Allen, 
which  I  have  found  peculiarly  helpful  in  the  care  of  patients. 

A.     NAUNYN'S  CONCEPTION  OF  DIABETES  MELLITUS. 

Xaunyn1  thoroughly  believes  in  the  unity  of  diabetes,  notwith- 
standing the  manifold,  and  even  doubtful,  causes  which  appear  to 
lead  up  to  it.  He  sees  in  heredity  the  common  bond  which  unites 
the  different  forms,  or  as  he  says,  "  to  speak  more  exactly,  the  hered- 
ity of  the  diabetic  tendency."  Variety  in  the  etiology  of  diabetes 
becomes  understandable  if  one  sees  in  the  disease  the  development 
of  an  individual  tendency.  Almost  any  illness  or  injury,  no  matter 
how  slight  it  may  be,  may  serve  as  a  cause.  Furthermore,  the 
experience  that  an  individual,  who  at  one  time  has  been  diabetic 
or  even  has  had  a  suspicions  glycosurin  which  has  passed  for  years 
as  cured  and  has  even  dropped  out  of  memory,  perhaps  for  decades, 
may  again  become  diabetic  under  favoring  influences,  is  in  con- 
formity with  this  view. 

This  diabetic  tendency  is  generally  congenital— indeed,  in  many 
cases  hereditary,  and  this  heredity  is  demonstrable  in  I'O  per  cent, 
of  the  cases.  These  cases  in  which  heredity  is  demonstrated  differ 
in  nowise  from  those  in  which  heredity  is  not  demonstrated.  This 
hereditary  tendency  is  associated  also  with  neuropathic  and  gouty 
tendencies. 

The  essential  point  in  the  diabetic  tendency  is  a  weakness  of  the 
metabolism  which  is  manifested  in  the  utilization  of  carbohydrate. 
Although  we  know  that  lesions  and  diseases  of  certain  organs,  above 


NAUNYN'S  CONCEPTION  OF  DIABETES  MELLITUS        75 

all  those  of  the  pancreas,  may  be  causes  of  this  disturbance  of 
metabolism,  it  may  well  be  that  the  diabetic  tendency  is  not  so 
much  to  be  sought  in  the  lessened  activity  of  one  of  these  organs 
as  in  the  disturbance  in  their  harmony  of  action.  At  this  stage  the 
manifestation  of  the  diabetic  tendency  is  still  shrouded  in  darkness, 
and  it  is  too  early  to  try  to  assign  it  to  the  pancreas  or  some  other 
of  the  diabetic  organs.  By  experiment  with  these  organs,  we 
know  that  diabetes  can  be  produced  even  without  any  individual 
tendency  to  it.  It  might  be  that  disturbances  in  the  function  of 
a  diabetic  organ  might  take  place  even  in  the  absence  of  causes  of 
diabetes.  But  this  does  not  appear  to  be  the  rule,  since  we  find 
among  the  cases  of  diabetes  of  the  nervous  and  hepatic-  type  the 
same  large  proportion  of  hereditary  cases  as  elsewhere. 

Besides  the  diseases  of  diabetic  organs,  we  have  as  causes  of 
diabetes  most  manifold  general  diseases  and  most  manifold  injuries, 
surgical  operations,  fits  of  anger,  overexertion,  indigestion,  excesses 
of  all  kinds,  and  it  is  hard  to  say  how  these  act.  Yet  this  is  certain, 
that  so  far  as  it  concerns  these,  we  are  dealing  only  with  an  existing 
tendency  which  has  been  let  loose  by  a  special  cause.  Whether  this 
is  connected  with  the  disease  of  one  of  the  diabetic  organs  is  hard 
to  say. 

According  to  the  manner  in  which  the  development  of  the 
diabetes  stands  to  the  diabetic  disposition,  Xaunyn  distinguishes 
three  forms  of  the  disease: 

1.  The  diabetes  of  young  people,  chiefly  between  thirty  and  forty 
years  of  age:    Xaunyn's  "true1  diabetes."    In  this  group  the  congeni- 
tal weakness  of  the  sugar  metabolism,  of  itself  or  often  in  conjunction 
with  some  accompanying  circumstance  (illness,  accident,  exertion, 
excesses),  may  lead  to  an  insufficiency  of  the  metabolism  of  sugar 
even  without  the  addition  of  the  disease  of  a  diabetic  organ.     In 
this  type   one  must  conceive  of  an  especially  severe  tendency  to 
the  disease,  and  this  accounts  for  the  especial  severity  of  its  form, 
but  only  in  part,  for  this  severity  depends  in  high  degree  upon  the 
great  demand  which  youth  makes  on  metabolism. 

2.  The  diabetes,  usually  mild,  of  elderly  people.     In  this  type, 
the  tendency  is  less  severe.    The  disease  comes  late  to  development, 
and  for  this  it  requires  a  lowering  of  the  vitality  which  comes  with 
age.     The  age  of  a  man  depends  on  the  condition  of  his  arteries. 
So  here,  too,  arteriosclerosis  comes  into  play,  and  with  the  arterio- 
sclerosis come  all  those  conditions  to  the  front  which  favor  the 
development    of    diabetes — overnutrition,    luxurious    living,    and 
especially  excesses   in   alcohol.     Syphilis,   which    is   so   important 
according  to  many  authors  in  the  cases  of  arteriosclerosis,  strange 

1  "Pure." 


76       FACTORS  L\   TREATMENT  OF  DIABETES  MELLITUS 

enough  to  say,  appears  to  play  no  great  role  here.  Just  as  old  age 
can  come  on  with  a  lowering  of  vitality  without  arteriosclerosis,  so, 
too,  a  growing  old  of  the  diabetic  organs,  quite  independent  of 
arteriosclerotic  processes,  may  he  important. 

)>.  The  organic  diabetes.  The  role  which  the  tendency  plays  in 
the  different  cases  of  this  group  varies.  In  general,  the  tendency  is 
present,  although  it  need  not  be.  To  the  organic  type  of  diabetes 
belong  those  eases  in  which  the  disease  of  the  diabetic  organs  appears 
as  the  cause  of  the  diabetes.  Thus,  diseases  of  the  liver,  of  the 
nervous  system,  whether  organic,  functional,  or  traumatic,  diseases 
of  the  thyroid  gland  and  of  the  pancreas  are  here  found,  and  the 
pancreas,  according  to  experiment  and  autopsy,  holds  the  first 
place.  In  these  organic  diseases  arteriosclerosis  is  important,  and 
in  this  way  arteriosclerosis  may  be  the  cause  of  diabetes. 

B.     ALLEN'S  HYPOTHESIS.     DIABETES-  A  WEAKNESS  OF 
THE  PANCREATIC  FUNCTION. 

Allen1  '-  sees  in  diabetes  a  weakness  of  the  pancreatic  function, 
and  he  was  led  to  this  view  through  his  own  experimental  work, 
as  well  as  that  of  others. 

1 .  The  Production  of  Diabetes. — Removal  of  portions  of  a  dog's 
pancreas  produces  a  lowering  of  the  sugar  tolerance.     Removal  of 
nine-tenths  of  the  gland   results  in   severe  diabetes.     When   the 
remnant  is  larger  (for  instance,  one-eighth)   milder  types  of  dia- 
betes result,   and  the  course  is  chronic,  extending  over  months, 
and  ends  fatally.    Such  animals  furnish  a  closer  imitation  of  human 
diabetes  than  is  produced  by  total  pancreatectomy. 

2.  Pathological  Anatomy  of  Diabetes. — In  the  foregoing  proced- 
ure duct  communication  between  the  pancreatic  remnant,  and  the 
duodenum  is  preserved,  and  in  consequence  the  acinar  tissue  does 
not  atrophy,  and  in  some  cases  it  may  hypertrophy.     The  islands 
of  Langerhans  show  typical  progressive  alterations,  which  may  be 
summarized  as  vacnolation  of  cytoplasm  and  loss  of  granulation, 
pyknosis  of  nuclei,  loss  of  cells,  and  finally  disappearance  of  islands. 
By  suitable  controls,  Allen  showed  the  changes  to  be  specific  in 
diabetes.     IIomans:!  has  made  a  careful  histological  study  of  such 
changes  in  the  islands  of  diabetic  cats  by  the  aid  of  the  admirable 
methods   of   Bensley. 

)>.  Pathological  Physiology  of  Diabetes.  An  idea  has  long  existed 
that  the  disturbance  of  carbohydrate  metabolism  in  diabetes  might 

1  Allen:      Studies  Coni-emim,'  Diabetes.  Jour.  Am.  Med.  Assn.,  1014.  Ixiii,  p.  fKW. 

-Allen:  Tin-  Treatment  of  Diabetes.  Huston  Med.  and  Sum.  Jour.,  I'.H."),  clxxii, 
p.  7i:i:  also  see  Jour.  Am.  Med.  Assn.,  I'.IUi.  xlvi.  p.  1.VJ.1.  Allen  and  DuHnis:  Arch. 
Int.  Med.,  I'.HO,  xvii,  p.  1010.  Allen:  Am.  Jour.  .Med.  Sc.,  1917,  eliii,  p.  JiKi. 

3  Ilonituis:      Jour.  Med.  Research,  l'Jl-1,  xxx,  p.  -10. 


ALLEN'S  HYPOTHESIS  77 

perhaps  be  explained  by  the  assumption  that  sugar  exists  in  a 
combined  form  in  the  normal  body,  but  that  this  combination  is 
lacking  in  diabetes.  This  combining  substance  has  been  designated 
by  Allen  with  the  figurative  title  of  "amboceptor,"  to  indicate 
its  function  as  a  bond  between  tissue  and  sugar.  The  substance 
which  thus  combines  with  dextrose,  or  some  link  in  the  combination, 
is  supposed  to  be  furnished  by  the  islands  of  Langerhans. 

It  was  pointed  out  by  Thiroloix  and  Jacob  that  some  dogs  after 
partial  pancreatectomy  are  free  from  glycosuria  on  a  meat  diet, 
but  show  glycosuria  when  carbohydrate  is  fed,  and  that  continuance 
of  carbohydrate  diet  finally  brings  the  animals  into  a  state  of  severe 
diabetes  in  which  they  excrete  sugar  even  on  meat  diet. 

Independently  of  these  writers,  Allen  made  similar  observations, 
and  thinking  them  of  much  importance,  repeated  and  extended  the 
work,  about  which  he  was  able  to  make  the  following  statements: 

After  removal  of  sufficiently  large  fractions  of  the  pancreas,  as 
above  described,  dogs  develop  a  severe  diabetes,  in  which  they 
show  heavy  glycosuria  on  meat  diet  and  also  during  considerable 
periods  of  fasting.  The  condition  progresses  steadily  downward  to 
a  fatal  end. 

\Vhen  the  remnant  of  the  pancreas  left  in  situ  is  slightly  larger, 
a  condition  may  be  produced  in  which  the  fate  depends  on  the  diet. 
On  meat  feeding  such  a  dog  is  free  from  glycosuria,  and  remains  so 
for  months,  eating  his  fill  every  day  and  maintaining  full  health 
and  nutrition,  with  no  sign  of  downward  progress,  but  subcutaneous 
tests  show  that  the  dextrose  tolerance  is  very  low,  and  bread  feed- 
ing readily  produces  glycosuria.  A  return  to  meat  diet  stops  the 
glycosuria;  but  if  the  bread  diet  and  accompanying  glycosuria  are 
maintained  for  too  long  a  time,  the  glycosuria  then  continues  even 
on  meat  feeding.  The  diabetes  thus  produced  is  not  inferior  in 
severity  to  that  resulting  from  simple  removal  of  larger  fractions 
of  pancreatic  tissue,  and  the  downward  course  and  fatal  termination 
are  similar. 

When  the  pancreatic  remnant  is  still  larger,  glycosuria  is  absent 
on  meat  diet,  and  on  bread  diet  may  be  absent  or  transitory.  Such 
animals  may  remain  in  excellent  condition  indefinitely  on  bread 
diet,  free  from  glycosuria  or  any  downward  tendency,  but  if  suffi- 
cient sugar  is  added  to  the  diet,  glycosuria  can  be  produced  and 
maintained.  After  a  period  of  such  glycosuria,  the  animal  reaches 
a  condition  in  which  it  has  glycosuria  on  bread  diet.  By  prolonging 
the  glycosuria  on  bread  diet,  the  dog  finally  reaches  the  condition 
of  severe  diabetes,  with  glycosuria  on  meat  diet,  and  continues 
downward  progress. 

When  the  pancreatic  remnant  is  still  larger,  sugar  feeding  may 
produce  transitory  glycosuria,  but  it  cannot  be  made  to  continue. 


7S       FACTOR*   /.V    TREATMENT  OF   DIABETES    MELLITUS 

The  sugar  tolerance  is  lower  than  in  normal  dogs,  hut  nevertheless 
the  doses  of  sugar  necessary  to  produce  glyeosuria  are  higher  than 
can  be  tolerated  as  a  daily  routine  l>y  the  gastro-intestinal  canal. 

The  changes  previously  described  as  occurring  in  the  islands  of 
Langerhaiis  occurred  whether  the  diabetes  followed  directly  on  the 
operation  alone,  or  was  induced  in  the  prepared  animal  by  means 
of  modification  of  diet.  The  best  of  the  control  animals  were  still 
alive  when  Allen  published  his  paper.  lie  found  the  control  tissues, 
examined  up  to  that  time,  indicated  that  in  animals  predisposed  by 
operation,  when  diabetes  is  prevented  by  the  carbohydrate-free 
diet,  the  signs  of  exhaustion  and  degeneration  in  the  islands  of 
Langerhans  were  absent.  lie  pointed  out  that  if  further  study 
shows  that  this  is  the  case,  it  will  a f lord  additional  evidence  that 
these  changes  have  a  direct  relation  to  the  diabetes  and  that  they 
are  a  result  of  functional  overstrain. 

In  a  Harvey  Lecture1  delivered  in  the  autumn  of  11)10,  Allen 
reported  his  MICCCSS  in  producing  acidosis  in  partially  depancreatized 
dogs.  These  observations  fill  in  the  gap  which  has  existed  between 
the  artificially  produced  diabetes  in  dogs  and  the  spontaneous 
diabetes  of  man.  The  significance  of  this  discovery  is  fully  as  great 
as  his  earlier  contribution  to  the  treatment  of  diabetes.  Heretofore 
attempts  to  combat  acidosis  have  been  limited  to  observations 
upon  human  beings,  but  now  experiments  upon  animals  can  be 
tried  and  the  knowledge  derived  thereby  will  be  applicable  to 
mankind. 

Taking  a  suitable  dog,  free  from  cachexia,  Allen  sketched  what 
happens  "when  lie  is  forced  either  to  hold  or  to  gain  weight  in  the 
presence  of  severe  diabetes.  lie  cannot  long  hold  weight  on  carbo- 
hydrate or  protein;  the  one  food  for  the  purpose  is  fat.  In  some 
dogs,  and  in  any  dog  if  the  diet  is  not  carefully  adjusted,  vomiting, 
diarrhea  and  loss  of  weight  prevent  a  perfect  result.  The  tendency 
to  digestive  disturbances  is  like  that  of  human  patients  on  similar 
treatment.  If  digestion  and  absorption  remain  adequate,  the 
breaking  do\vn  of  metabolism  is  manifested  by  increasing  acidosis. 
There  is  repugnance  to  fat  and  hunger  for  carbohydrate  as  in  human 
patients,  but  the  animal's  \vi>hes  must  be  disregarded  as  has  been 
done  in  human  case>.  and  the  fat  given  forcibly  if  necessary.  The 
highest  fat  diet  is  the  most  quickly  toxic,  but  excessive  quantities 
of  fat  are  not  required,  and  both  protein  and  carbohydrate  aid 
digestion  and  do  not  interfere  with  the  result,  so  long  as  fat  is 
continued.  For  the  sixe  of  dogs  used,  the  acidosis  diet  has  some- 
times been  I  .">()  to  200  gin.  suet  and  L'OO  to  100  gin.  beef-lung,  or 
100  to  1.10  gni.  suet,  '200  gin.  lung  and  ">0  to  1.10  gm.  bread.  Lipemia 

1  Allen:  Am.  Jour.  M^l.  Sc.,  1917.  cliii 


ALLEX'S   IIYl'orilKMK  79 


is  present;  there  is  malaise  and  depression  of  spirits  as  in  patients 
with  aeidosis,  and  digestive  upsets  increase.  If  the  animal  is  well 
suited  for  the  purpose,  if  the  diet  is  properly  adjusted,  and  if  there 
is  enough  day  and  night  watching  of  all  details,  it  can  be  shown  that 
dogs  thus  go  into  fatal  diabetic  coma  on  full  mixed  diet. 

"Second,  we  may  take  the  customary  treatment  of  moderate 
diabetes  and  illustrate  it  in  dogs.  Suppose  that  suitable  operation 
and  overfeeding  have  produced  a  condition  where  there  is  marked 
glycosuria  on  a  kilogram  of  lung,  but  sugar-freedom  on  M)()  gm. 
lung,  along  with  a  fair  state  of  nutrition  and  entire  absence  of 
ketonuria.  Now  place  the  dog  on  (>00  to  SOO  gm.  lung  and  100 
to  200  gm.  suet,  according  to  the  classical  method.  There  is  no 
glycosuria,  weight  is  gained,  and  the  condition  is  splendid  for 
weeks  and  possibly  months.  The  treatment  is  highly  successful. 
Closer  examination  shows  the  presence  of  hyperglyeemia  and  slight 
ketonuria,  which  are  usual  in  the  patients  of  corresponding  type. 
(Hycosuria  follows,  illustrating  the  spontaneous  downward  progress 
which  the  authorities  describe.  This  is  cleared  up  by  a  few  fast 
days  on  the  Xaunyn  plan,  and  the  diet  is  again  adjusted;  it  may 
now  be  400  gm.  lung  and  200  gm.  suet.  The  gain  in  weight  continues 
as  before,  with  hyperglyeemia,  ketonuria,  and  subsequent  glycosuria. 
Againlhe  fast  days  are  used  and  the  protein  diminished  so  that  the 
diet  is  perhaps  200  gm.  lung  and  200  gm.  suet.  The  same  cycle  is 
repeated.  Now  the  dog  is  in  splendid  condition  and  spirits,  the 
coat  sleek,  the  appearance  such  that  he  might  create  a  good  impres- 
sion out  walking  in  the  park,  only  he  has  difficulty  in  remaining 
sugar-free  on  even  the  protein  minimum,  and  the  fat  may  be  pushed 
higher  to  maintain  nutrition  against  the  repeated  fast  days.  If  the 
dog  has  actually  been  kept  fat,  a  fasting  period  about  this  time  may 
diminish  tin'  glycosuria  or  it  may  remain  high.  The  previously 
lively  and  hungry  animal  begins  to  show  a  curious  little  mournful- 
ness,  and  complete  repugnance  to  food.  A  day  or  two  later,  vomiting 
of  clear  mucus  begins,  and  the  dog  drinks  and  vomits  water.  The 
acetone  reaction  is  heavy;  the  ferric  chloride  may  be  heavy  or 
slight.  The  alkali  reserve  of  the  blood  falls  low,  and  the  complete 
picture  of  patients  who  go  into  fatal  aeidosis  on  fasting  is  reproduced. 
Dogs  of  the  type  first  described  are  also  subject  to  this  result  of 
fasting  if  they  have  been  kept  fat  enough,  but  fattening  is  easiest 
in  absence  of  glycosuria. 

"The  third  type  of  aeidosis  in  dogs  is  exemplified  by  diabetic 
animals  kept  free  from  glycosuria  by  regulated  diet,  or  by  those  in 
which  the  amount  of  pancreatic  tissue  removed  is  not  quite  sufficient 
to  give  rise  to  diabetes.  They  are  free  from  aeidosis  on  protein 
diet  or  on  fasting;  but  on  a  carbohydrate-free  diet  high  in  fat  they 
sooner  or  later  develop  marked  ketonuria.  The  protein  ration  may 


SO       FACTORS   IX    TREATMENT  OF   DIABETES   MELLITUS 

be  governed  by  the  capaeity  of  the  stomach.  Probably  high  protein 
tends  to  increase  susceptibility  to  diabetic  glycosuria  and  diminish 
the  tendency  to  ketonnria.  1  hose  experiments  also  may  extend 
over  weeks  or  months,  but  we  have  proved  upon  many  dogs  that, 
with  enough  fat  in  the  diet  the  result  is  invariable.  The  qualitative 
acetone  test  is  heavy  but  the  quantitative  output  relatively  small, 
generally  below  1  gram.  Partially  depancreati/ed  non-diabetic 
dogs  on  a  diet  of  150  to  MOO  gm.  snet  and  perhaps  an  equal  amount 
of  lung,  may  thrive  in  spite  of  ketonnria  for  a  longer  or  shorter 
time.  Ketonuria  is  apt  to  be  slight.  But  the  final  outcome  appears 
in  one  or  two  forms.  One  may  be  digestive  failure  and  consequent 
loss  of  weight  and  strength,  with  cessation  of  ketonuria.  In  the 
other  form,  the  routine  measures  against  vomiting  and  diarrhea 
may  succeed,  but  at  the  end  there  is  foul  breath,  fatty  feces,  pros- 
tration, muscle-quiverings  or  actual  convulsions,  da/ed  mentality 
and  sometimes  total  unconsciousness.  Against  forced  feeding  the 
organism  protects  itself  by  vomiting,  diarrhea,  and  remarkable 
cessation  of  absorption.  The  small  proportion  of  protein  contained 
in  cream  or  snet  gives  little  protection.  The  same  result  follows 
more  slowly  whenever  the  proportion  of  fat  to  protein  or  carbo- 
hydrate in  the  diet  is  too  high.  The  craving  of  diabetic  patients 
for  carbohydrate  is  often  illustrated  in  such  dogs.  It  should  be 
worth  while  to  determine  a  law  of  balance  for  normal  animals.  Not 
only  has  the  diabetic  animal  a  specific  sensitiveness  to  fat,  but  on 
low  protein  ration  it  must  be  unable  to  bear  as  much  fat  as  an  animal 
on  high  protein.  If  the  danger  of  glycosuria  prevents  increasing 
the  protein,  intoxication  can  be  avoided  by  diminishing  the  fat. 
The  animal  is  thinner  but  safer,  hungry  instead  of  nauseated.  The 
large  quantity  of  fat  in  the  diet  led  patients  to  acquire  a  repugnance 
to  the  prescribed  diet  and  refuse  to  endure  it.  By  will-power  they 
sometimes  endure  it  for  a  time.  They  live  in  fair  comfort  on 
moderate  protein  and  little  or  no  carbohydrate'  as  long  as  the  fat 
is  kept  suitably  low.  They  behave  much  more  rationally  toward 
simple  hunger  for  all  classes  of  foods  than  they  did  toward  the 
former  excessive  craving  for  carbohydrate.  Lack  of  self-control 
still  claims  many  victims,  but  the  proportion  of  patients  willing  to 
follow  diet  faithfully  has  been  increased  by  reason  of  the  more 
natural  balance  of  foods  in  the  diet." 

While  various  factors  are  undoubtedly  concerned  in  the  produc- 
tion of  human  diabetes,  clinical  observations  indicate'  that  diet  is 
an  important  one.  It  is  generally  recognized  that  there  is  a  higher 
incidence  of  diabetes  among  those'  races  or  classes  of  people  who 
use  an  excess  of  carbohydrate.  Luxurious  living  and  seden- 
tary life  are  thought  to  predispose  to  this  disorder.  The  experi- 
mental observations  on  animals  suggest  an  explanation  of  this 


ALLEN'S  HYPOTHESIS  81 

relationship  between  diet  and  diabetes  in  the  human  subject.  If 
individuals  differ  in  the  strength  of  the  pancreatic  function  as  in 
other  functions,  in  some  this  may  be  so  weak  that  diabetes  comes 
on  in  early  life  irrespective  of  the  diet.  In  others  this  function  may 
be  only  a  little  stronger,  so  that  diabetes  may  be  delayed  until 
later  in  life,  or  even  to  the  period  of  senility,  when  there  occurs  an 
impairment  of  various  functions.  Others  may  be  more  or  less  below 
the  average  in  pancreatic  functional  power,  but  under  ordinary 
circumstances  this  is  sufficient  to  prevent  the  occurrence  of  diabetes. 
In  these  persons,  however,  who  might  otherwise  go  through  life 
with  no  sign  of  diabetes,  an  excess  of  starch  in  the  diet  may  serve 
as  an  exciting  cause  of  diabetes,  and  the  degree  of  such  excess  may 
help  to  determine  the  earlier  or  later  onset  and  the  milder  or  severer 
type  of  the  disorder.  In  other  persons  of  this  sort,  as  in  the  corre- 
sponding type  of  dogs,  the  pancreatic  function  is  able  to  deal  safely 
with  as  much  starch  as  can  be  digested,  but  a  sufficient  excess  of 
sugar  is  an  effectual  cause  of  diabetes. 

It  is  impossible  to  produce  diabetes  in  the  normal  dog  by  an 
excess  of  carbohydrate  feeding,  since  if  too  much  sweet  or  starchy 
food  is  taken,  indigestion  results  and  automatically  stops  the  inges- 
tion.  But  in  dogs  after  operation  and  in  predisposed  human 
patients,  pancreatic  weakness  may  reverse  the  normal  relation,  so 
that  the  organism  can  digest  and  absorb  more  carbohydrate  than 
it  can  combine  and  assimilate,  and  in  this  condition  the  production 
of  diabetes  by  improper  diet  is  possible. 

The  best  established  and  most  generally  accepted  theory  is  that 
diabetes  results  from  deficiency  of  the  internal  secretion  of  the  pan- 
creas. In  a  relatively  small  number  of  cases  there  is  gross  destruc- 
tion of  pancreatic  tissue  by  infection  or  otherwise,  and  here  early 
surgical  intervention,  in  the  form  of  drainage  of  the  gall-bladder  or 
other  suitable  measures,  is  presumably  the  most  important  treat- 
ment. In  the  great  majority  of  cases  the  gross  appearance  of  the 
pancreas  is  normal.  Changes  in  the  islands  of  Langerhans  occur 
in  animals  with  experimental  diabetes,  and  changes  in  the  islands 
of  human  patients  are  being  found  more  frequently  as  they  are 
sought  more  carefully.  Even  after  the  longest  and  severest  clinical 
diabetes,  changes  in  the  islands  may  be  difficult  to  discover,  and 
complete  destruction  of  all  the  islands  in  the  human  pancreas  must 
be  a  great  rarity,  if  it  ever  occurs.  In  animals  the  islet  changes 
are  secondary  to  the  diabetes.  In  human  cases  it  is  still  unknown 
to  what  extent  the  changes  are  primary,  producing  the  diabetes, 
or  to  what  extent  they  may  be  secondary,  produced  by  the  diabetes. 
It  seems  that  a  considerable  functional  factor  is  generally  present; 
that  we  are  never  dealing  with  destruction  of  tissue  which  cannot 
be  replaced,  but  always  with  a  certain  element  of  disturbed  function, 
6 


82       FACTORS   IX    TREATMEXT  OF   DIABETEH   MELLITUS 

which  can  be  broken  down  by  overstrain  or  strengthened  by  rest. 
On  the  other  hand,  a  full  return  to  normal  function  is  practically 
never  obtainable. 

Allen  cites  Macleod's1  simple  objective  description  of  diabetes. 
Maeleod  states  how  it  appears  at  first  as  a  weakened  function  of 
carbohydrate  metabolism,  next  there  is  a  weakened  function  of 
protein  metabolism,  and  then  in  the  severe  cases  an  imperfect 
metabolism  of  fat.  Allen  says  that  if  we  follow  this  plain,  simple 
idea,  it  guides  us  to  a  rational  therapy.  Diabetes  is  commonly 
looked  upon  as  a  progressive,  fatal  disease.  Of  course  in  one  sense 
it  is  a  disease.  But  in  another  sense  it  may  be  beneficial  to  implant 
the  idea  in  both  physicians  and  patients  that  diabetes  is  not  a  disease, 
lie  considers  that  there  is  no  evidence  that  it  is  an  infection,  or  an 
auto-intoxication,  or  anything  else  of  that  order.  He  is  not  aware 
that  an  inherent  downward  tendency  has  ever  yet  been  demonstrated 
in  typical  cases.  For  practical  purposes  he  believes  in  keeping  to 
the  simple  idea  mentioned  above,  that  diabetes  is  merely  the  weak- 
ness of  a  bodily  function,  namely,  the  function  of  assimilating 
certain  foods.  If  diabetes  is  a  weakness  of  the  pancreatic  function, 
one  can  understand  why  the  break-down  is  most  frequent  in  elderly 
persons,  but  generally  most  serious  in  young  persons,  as  emphasized 
by  Xaunyn.  If  a  person  overtaxes  a  weak  stomach,  the  resulting 
distress  punishes  the  error  and  forces  him  to  desist.  If  he  overtaxes 
a  weak  pancreas,  nothing  but  intelligence  can  show  him  what  is 
wrong.  But  if  the  conception  is  correct  of  diabetes  as  the  simple 
weakness  of  a  bodily  function  without  inherent  downward  tendency, 
then  if  the  patient  is  obedient  he  may  be  kept  from  going  down 
hill  simply  by  preventing  him  from  overtaxing  his  weakened  func- 
tion. The  weak  pancreas  may  never  become  a  strong  pancreas. 
The  patient  may  never  be  entirely  normal  again.  But  Allen  believes 
that  if  this  idea  is  fully  correct,  this  precaution  may  save  life. 

C.     IS  THE   TENDENCY    OF  THE  DIABETIC   GLYCOSURIA 
TO  INCREASE? 

Hitherto  most  writers  have  been  unanimous  in  the  belief  that 
the  tendency  of  the  diabetic  glycosuria,  particularly  if  untreated, 
is  to  increase.  There  are  numerous  exceptions  to  the  rule,  if  the 
diabetes  has  been  treated,  but  I  know  of  none  where  the  disease 
has  been  allowed  to  take  its  course  without  medical  intervention. 
Since  my  assistant,  Dr.  Ilornor,  and  I  have  paid  especial  attention 
to  the  group  of  diabetics  of  fifteen  or  more  years'  duration,  a  good 
many  cases  have  come  to  light  in  which  the  disease  has  shown  little 

1  Muck'od:    Jour.  Am.  Mvd.  A^n.,  1'Jl  1.  l.xii.  p.  1222. 


IS   THE   TENDENCY  OF  DIABETES   TO  INCREASE          83 

if  any  progress.  All  of  these  patients,  however,  have  been  treated 
to  a  certain  extent  and  though  the  treatment  may  have  been  very 
slight,  strictly  speaking,  it  has  been  enough  to  take  them  out  of  the 
class  of  untreated  cases.  If  treatment  has  been  thorough  the 
question  changes  and  an  answer  to  it  will  be  found  in  the  following 
section  (I)).  Nevertheless,  even  with  some  cases  treated  most 
conscientiously  in  the  past  the  diabetes  has  become  more  severe. 
In  the  future  I  believe  it  will  continue  to  do  so  in  a  much  smaller 
number  of  instances.  This  forecast  is  based  upon  the  favorable 
course  in  the  past  of  many  mild  cases  and  the  ease  with  which 
cases  rather  more  severe,  in  character  are  now  controlled. 

Case  Xo.  8  shows  this  tendency  of  the  glycosuria  to  increase. 
The  case  dates  back  many  years  and  of  course  strictly  modern 
methods  were  not  followed,  yet  the  patient  was  carefully  treated. 
The  description  of  the  case  is  as  follows: 

A  woman  showed  the  first  symptom  of  diabetes  in  the  spring 
of  1899,  at  the  age  of  sixty  years,  and  5  per  cent,  of  sugar  was 
found  in  June.  She  had  gradually  lost  during  the  preceding  fifteen 
years  20  pounds,  and  weighed  105  pounds  when  the  diagnosis  was 
made.  Under  rigid  diet  the  urine  promptly  became  sugar-free; 
the  tolerance  rose  to  130  grams  and  save  for  very  transitory  intervals 
remained  so  for  nine  years,  until  1908.  During  1908  and  until  the 
autumn  of  1909  it  returned,  but  except  at  one  analysis  was  less 
than  1  per  cent.  In  October,  1909,  the  sugar  amounted  to  4.0 
per  cent.,  and  a  carbuncle  appeared.  With  prompt  surgical  care, 
vaccines,  the  restriction  of  carbohydrates,  and  the  temporary 
utilization  of  the  oatmeal  diet,  the  sugar  disappeared,  and  the 
carbuncle  healed  promptly.  But  the  urine  did  not  remain  per- 
manently sugar-free,  although  only  about  30  grams  of  sugar  were 
excreted  daily.  In  the  spring  of  1911,  the  sugar  again  rose  at  the 
time  of  an  attack  of  lobar  pneumonia,  but  as  recovery  took  place 
and  a  restricted  diet  was  instituted,  the  sugar  disappeared.  Kvi- 
dently  the  patient  could  be  freed  from  sugar,  but  upon  a  diet 
containing  only  about  30  grams  of  carbohydrate.  This  seemed  too 
narrow  (compare  treatment  in  1912  and  now)  for  the  patient  after 
thirteen  years  of  dieting,  so  that  it  was  practically  impossible 
to  keep  the  urine  free  from  sugar  continually.  Residence  in  a 
hospital  for  a  few  days  in  September,  1912,  in  order  to  have  several 
teeth  removed,  lowered  the  sugar  to  O.S  per  cent. 

Except  for  the  brief  periods  of  illness  due  to  the  carbuncle  and 
pneumonia,  the  patient  remained  well  during  all  these  years,  and 
was  unusually  strong  and  vigorous  for  a  woman  of  seventy-three 
years,  until  she  finally  succumbed  to  a  lingering  illness  subsequent 
to  a  hemiplegia,  and  death  finally  occurred  due  to  a  terminal 
pneumonia  in  1913. 


84       FACTOR*  IX    TREATMENT    OF   DIABETES   MKLLITVK 

Yet  I  confess  that  doubt  arises  as  to  the  progressive  character 

of  the  disease  when  one  sees  a  ease  of  diabetes  such  as  Case  Xo. 
l(i(),  who  was  untreated  for  years,  and  yet  was  able  to  become 
sugar-free  with  restricted  diet,  and  apparently  was  able  to  acquire 
a  tolerance  for  20  grams  carbohydrate.  If  the  disease  was  actually 
progressive,  then  such  a  patient  should  ultimately,  barring  death 
from  accidental  causes,  lose  all  tolerance  for  carbohydrate,  but  a 
case  of  this  type  has  not  yet  come  to  my  observation.  1  confess  that 
these  long-standing,  neglected  cases  are  apparently  easily  amenable 
to  modern  treatment,  but  the  question  arises  as  to  whether  they  can 
be  kept  in  a  sugar-free  condition  and  maintain  Aveight  consistent 
with  life.  Case  Xo.  !!)()  has  had  diabetes  for  twelve  years,  and 
still  has  a  carbohydrate  tolerance  for  IS  grains.  Case  Xo.  .'>.")  2  has 
had  diabetes  for  ten  years,  and  has  a  carbohydrate  tolerance  for 
2(>  grams. 

The  attractive  illustration  cited  by  von  Xoorden  to  show  the 
decrease  in  tolerance  with  neglect  of  treatment  will  not  help  with 
our  present  knowledge.  The  steady  loss  of  tolerance  in  his  case 
during  one  month  would  appear  to  prove  the  point,  but  today  we 
know  that  the  possibility  of  storage  of  carbohydrate,  or  rather  the 
lack  of  storage  of  an  excess  of  carbohydrate,  in  the  body,  must  be 
considered  in  any  such  experiment,  and  in  the  case  as  reported  by 
von  Xoorden,  determinations  of  sugar  in  the  blood,  determinations 
of  the  respiratory  quotient  and  changes  in  the  weight,  of  the  patient 
were  not  recorded. 

Further  evidence  of  value  would  be  afforded  by  a  study  of  very 
mild  cases  of  diabetes  discovered  by  routine  or  insurance.  If  such 
easels,  often  very  little  treated,  remained  stationary  for  years,  it 
would  be  evidence  against  a  progressive  tendency.  I'pon  this  point 
(>2  cases,  which  have  extended  over  a  period  of  fifteen  or  more 
years,  offer  some  information.  X'early  all  of  the  )>7  cases  now  liv- 
ing appear  today  in  about  the  same  condition  as  for  several  years. 

A  low  percentage  of  blood  sugar  in  cases  of  long  duration  is  also 
evidence  against  a  progressive  tendency.  Thus  in  the  (>2  cases  of 
fifteen  or  more  years'  duration,  of  the  !>(')  analyses  of  blood  sugar 
which  have  been  made,  20  were  under  0.20  per  cent.,  10  were  be- 
tween 0.21  and  0.2.">  per  cent.,  and  (>  between  0.2(1  and  0.4M  percent. 

D.     GAIN  IN  TOLERANCE   FOR  CARBOHYDRATES  WHEN 
URINE  IS   SUGAR  FREE. 

The  tendency  of  the  diabetic  patient  to  gain  in  tolerance  for  car- 
bohydrates when  the  urine  becomes  sugar-free  is  the  fundamental 
principle  upon  which  all  treatment  has  been  and  is  rightly  based, 
and  that  by  which  the  value  of  all  therapeutic  measures  is  deter- 


THE   TOLERANCE  FOR  CARBOHYDRATES 


85 


mined.  This  proposition  is  a  reverse  of  the  preceding,  and  it  would 
appear  to  hold  so  far  as  evidence  is  available,  both  experimentally 
and  clinically,  yet  here  again  the  evidence  should  be  far  more 
carefully  weighed  than  heretofore.  I  have  particularly  observed 
this  question  of  a  gain  in  tolerance  among  my  cases  of  long  duration 
who  have  become  sugar-free  in  the  last  year,  and  it  is  my  general 
impression  that  even  these  cases  increase  their  tolerance.  Case  Xo. 
194  is  an  excellent  illustration  of  this  gain  in  carbohydrate  tolerance 
in  a  child  and  its  later  loss  when  the  treatment  was  interrupted. 


TABLE  45. — CHART  OF  CASE  Xo.  194.     VARIATIONS  i.\  CARBOHYDRATE 

TOLERANCE. 


o 
Q 

Volume,  c.c. 

Diacetic  acid. 

££ 

«M 
•°"O" 

0  X 

4. 

Nitrogen,  gin. 

Sugar  in 

urine. 

•  255         si 

§3      :  |     .    ,  -|    ^ 

«  *j        rj  be  I  "£  bfi 

"^                 £H            •    rH 

2  S: 

—  £ 

o 

Carbohydrate 

balance,  gin. 

NaIICO3,  gin. 

Naked  weight 
of  patient, 
kilos 

1908 

April  ls-19 

1800 

+ 

50 

90 

+40 

8 

19-20 

2610 

— 

1.9      .  . 

7S 

90 

+  10 

8 

49.2 

20-21 

1710 

+  + 

44 

04 

+20 

8 

49.2 

21-22 

1890 

+  + 

00 

60 

8 

49.2 

22-23 

1000 

+ 

20  .  1 

1.9  r   .. 

42 

GO 

+20 

8 

49.4 

23-24 

1650 

+ 

20 

40 

+20 

8 

49.5 

24-25 

1650 

+ 

17 

20 

+5 

8 

49.0 

25-26 

1590 

+ 

10 

15 

— 

8 

50.2 

26-27 

2970 

+ 

1.5        0 

12 

10 

— 

8 

50.4 

27-28 

1050 

0 

0 

— 

12 

+  10 

8 

50.0 

May      1-  2 

1830 

0 

13.0 

0 

— 

10 

+  15 

0      50  .  2 

Nov.  11-12 

1500 

0 

0 

50  ± 

+50 

0      53  .  0 

1909 

Fob.      1-   2 

1520 

0 

0 

90  ± 

+90 

0 

May   10-11 

0 

0 

90  ± 

+90 

0  i  55.9 

July    27-28 

0 

!0± 

+90 

0      55.9 

Sept.  18-19 

2820 

— 

13.0      0.5      17 

11 

15 

— 

20      53  .  0 

22-23 

3280 

+  +  + 

13.0      11.2      0.6     42 

24 

15 

-25 

20      52  .  9 

23-24 

2577 

+  +  + 

14.3        8.0      0.5      50 

43 

105 

4115 

20      52  .  3 

24-25 

2410 

+  +  + 

14.1      10.0        ..        19 

— 

15 

—  5 

20      52  .  0 

1910 

Oct.    25-26 

2300 

+  +  + 

15.9      2.4      80 

04 

— 

— 

-      53  .  6 

Nov.  29-30 

2000 

+  +  + 

+ 

04 

— 

— 

-      52.6 

Dec.    10 

Death  i 

n  coma. 

Female,  born  August  16,  1S93,  single,  no  occupation,  onset  of 
diabetes  at  age  of  thirteen  years  in  February,  190S;  sugar  in  the 
urine  March,  1U)S;  came  under  observation  April  IS,  190S;  died 
in  coma  December  10,  1910.  There  was  no  history  of  diabetes  in 
the  family.  Father  died  of  pneumonia,  mother  and  brother  well. 
The  past  history  included  scarlet  fever,  dysentery  at  three  years 
of  age,  measles,  mumps,  whooping-cough,  chicken-pox,  enuresis  noc- 


80       FACTORS  IX   TREATMENT  OF  DIABETES  MELLITUS 

turna  which  ceased  at  the  age  of  four  years.  (I  have  repeatedly 
observed  this  symptom  in  the  early  history  of  diabetic  children.) 
Always  a  voracious  appetite,  sometimes  eating  six  potatoes  at  a 
meal;  ate  much  candy.  1  hiring  the  year  preceding  the  onset  of  the 
disease  the  patient  developed  rapidly  both  in  height  and  weight.  In 
February,  190S,  she  showed  weariness.  Karly  in  March  polydipsia, 
polyuria  and  polyphagia  were  present,  and  sugar  was  demonstrated 
in  the  urine.  In  the  previous  year  the  urine  was  normal. 

During  the  whole  period  of  illness  the  patient  remained  in  good 
condition  and  attended  school  with  comfort.  The  diet  was  rigidly 
adhered  to  and  not  relaxed  except  when  the  diagnosis  was  at  one 
time  doubted  by  the  local  physician.  Catamenia  was  established 
for  the  first  time  in  March,  1900.  The  patient  died  in  coma  on 
December  10,  1010. 

Case  No.  f)f>4  (see  p.  27X)  shows  a  remarkable  gain  in  tolerance 
from  a  minus  carbohydrate  balance  of  50  grams  to  a  positive  balance 
of  o5  grams,  lasting  for  years.  Case  No.  2(K>  (see  p.  52)  also  illus- 
trates a  gain  in  tolerance,  for  now  this  boy  is  able  to  take  a  free  diet 
without  the  appearance  of  sugar.  Case  Xo.  (>5.'>  showed  5.S  per  cent, 
and  174  grams  sugar  on  a  free  diet  in  September,  191.'->,  but  now, 
three  and  a  half  years  later,  at  the  age  of  fifty-six  years,  eats  between 
200  and  .'!00  grams  carbohydrate  and  is  free  from  sugar.  This 
patient,  like  several  others,  takes  comparatively  little  fat.  The 
remarkable  case  of  (ieyelin  and  DuBois,1  who  progressed  from  a 
minus  carbohydrate  balance  of  75  grams  to  a  positive  balance  of 
1(50  grams,  is  another  striking  illustration  of  gain  in  tolerance. 
Case  No.  30  showed  sugar  for  IS  years,  and  yet  now,  on  a  very 
liberal  diet,  is  sugar-free.  Case  Xo.  )>21  had  a  tolerance  for  90 
grams  carbohydrate  in  1910,  at  the  age  of  fifty-six  years,  but  now 
takes  carbohydrate  LSI  grains,  protein  57  grains  and  fat  102  grams, 
without  a  trace  of  sugar.  Case  Xo.  (>.'>2  (see  p.  )>S2)  had  difficulty 
in  becoming  sugar-free  in  July,  191.'),  ;it  the  age  of  thirty-one  years, 
upon  carbohydrate  15  grams,  but  now  maintains  an  active  life, 
playing  golf  better  than  ever,  and  has  reached  a  position  of  emi- 
nence in  his  country  in  his  military  vocation,  yet  he  keeps  sugar- 
free4  upon  a  diet  of  carbohydrate  29  grams,  protein  S5  grams,  and 
fat  150  grams. 

In  general  it  may  be  said  that  a  gain  in  weight  of  a  diabetic 
patient  lasting  for  several  years,  in  conjunction  with  a  sugar-free 
urine,  can  only  take  place  when  the  total  diet,  in  other  words  the 
total  food  tolerance  of  the  patient,  has  increased. 

The  best  writers  are  all  most  emphatic  in  their  approval  of  the 
endeavor  to  promote  tolerance  for  sugar  by  rendering  the  patient 

1  Gcyclin  and  DuBois;  Lnc.  cil.,  p.  112. 


HYPERGLYCEMIA  87 

sugar-free.  Xaiinyn  says,  "  From  my  experience  I  consider  it 
highly  ])rol)al)le  that  among  the  early,  strictly  treated  cases  which 
passed  in  the  beginning  as  severe,  but  later  took  a  favorable  course, 
there  is  many  a  one  for  which  one  must  thank  this  early  strict  treat- 
ment; moreover,  on  the  other  hand,  there  can  be  no  doubt  that 
the  cases  which  run  ultimately  a  severe  course  have  undergone  little, 
if  any,  energetic  care."  And  again  he  urges  not  to  be  "content 
to  maintain  the  patient  for  a  time  in  just  an  endurable  condition, 
but  rather  to  strive  to  improve  the  diseased  function,  or  at  least 
hold  in  check  further  inroads  on  the  same."  So  universal  are  the  two 
principles  that  there  is  an  increase  in  severity  the  longer  the  disease 
lasts  and  that  the  progress  of  the  disease  is  checked  by  making 
the  patient  sugar-free,  that  it  makes  any  glycosuria,  no  matter  how 
inconsiderable,  worthy  of  energetic  treatment. 

E.     HYPERGLYCEMIA. 

The  percentage  of  sugar  in  the  blood  of  normal  individuals 
ranges  from  0.0(i  per  cent,  to  0.1 1  per  cent.,  most  of  the  observations 
being  in  the  neighborhood  of  0.10  per  cent.  In  diabetes  the  per- 
centage of  sugar  rises,  and  in  the  untreated  diabetic  usually  lies 
between  0.20  to  0.40  per  cent.  Under  treatment,  it  may  fall  to 
normal.  In  a  few  cases  values  are  obtained  above  0.40  per  cent., 
but,  as  a  rule,  such  cases  appear  to  be  on  the  verge  of  coma, 
complicated  with  nephritis,  or  as  in  Case  Xo.  1015,  associated  with 
suppression  of  urine. 

The  percentage  of  sugar  in  the  blood  of  normal  individuals  rises 
promptly  after  a  meal,  and  may  reach  0.17  per  cent.  This  is  due 
to  the  carbohydrate  and  the  protein  as  well  in  the  food.  Jacobsen1 
observed  in  15  persons  receiving  100  grams  dextrose  on  an  empty 
stomach  before  breakfast  a  hyperglycemia  which  usually  occurred 
within  half  an  hour.  He  also  made  the  interesting  observation 
that  of  14  persons  receiving  107  grains  of  bread,  all  reacted  with 
hyperglycemia  and  0  with  glycosuria.  The  only  difference  in 
action  between  the  dextrose  and  the  bread  was  in  the  rapidity  of  the 
rise  and  fall  of  the  sugar  curve,  and  this  could  be  explained  by  the 
difference  in  the  rate  of  absorption. 

Strouse-  has  reached  similar  conclusions.  His  analyses  show  that 
there  is  no  fixed  value  for  the  normal  blood  sugar,  and  the  normal 
varies  with  each  individual  depending  on  the  diet. 

In  two  or  three  hours  after  the  administration  of  100  grams 
glucose  to  normal  individuals,  the  percentage  of  sugar  in  the  blood 
may  fall  below  normal,  but  with  diabetics  the  maximum  is  usually 

1  Jacobson:    Biochem.  Ztschr.,  1913,  Ivi,  p.  471. 

2  Strouse'    Johns  Hopkins  Hosp.  Bull.,  1915,  xxvi,  p.  214. 


88       FACTORS  IX   TREATMENT  OF  DIABETES   MELLITUS 

reached  in  two  hours,  but  the  decline  often  occupies  eight  to  ten 
hours.' 

Other  causes  than  food  may  raise  the  percentage  of  sugar  in  the 
blood.  It  may  be  increased  in  apoplexy,  pneumonia,  typhoid, 
tuberculosis  in  the  presence  of  fever  and  in  some  cases  of  cancer. 
There  is  a  decided  increase  after  ether  anesthesia  and  in  operations 
on  all  kinds  of  cases.  If  the  anesthesia  is  less  than  an  hour  the 
increase  is  .">2  to  89  per  cent.,  but  if  more  than  an  hour  the  increase 
is  greater.  Tain,  fear  of  operation  or  of  anesthesia  exert  a  negligible 
influence  upon  the  blood  sugar.2 

Epstein  and  Baehr3  have  drawn  attention  to  the  significance  of 
blood  volume  in  blood-sugar  estimations.  They  point  out  that  the 
increase  in  the  percentage  of  sugar  in  the  blood  is  only  indicative 
of  a  relative,  that  is  percentile,  but  not  of  absolute  hyperglyeemia, 
and  suggest  the  advisability  of  studying  the  blood  volumes  and  com- 
puting thereby  the  total  blood  sugar  in  cases  of  diabetes  mellitus, 
and  in  a  later  publication4  Epstein  defines  "hyperglyeemia  as  an 
increase  in  the  total  amount  of  blood  sugar  over  the  normal,  and 
not  merely  an  increase  in  concentration  or  percentage.  Thus  it 
is  possible  to  have  a  hyperglyeemia  even  when  the  percentage  of 
sugar  is  normal  or  below  normal." 

Recently  Myers  and  Bailey5  have  recorded  a  series  of  blood- 
sugar  determinations  in  diabetics  with  nephritis  in  which  the  per- 
centage of  sugar  varied  between  0.19  and  O.SO  per  cent.  In  the  last 
instance;  the  patient  died  the  day  after  the  observation,  and  there 
was  evidence  of  nitrogen  retention,  as  shown  by  the  presence  of 
55  mg.  of  urea  nitrogen  per  lOOc.c.  of  blood.  Ilagelburg'' found  an 
abnormally  high  sugar  content  in  the  blood  in  2(5  cases  of  nephritis 
or  arteriosclerosis,  or  both  combined.  For  my  own  experience 
with  patients  having  Bright's  disease  see  p.  419. 

Case  Xo.  1015  of  my  series  deserves  detailed  mention  because  the 
percentage'  of  sugar  found  in  the  blood,  so  far  as  I  am  aware,  exceeds 
that  hitherto  reported.  A  schoolmaster,  aged  forty-seven  years, 
highest  weight  21(5  pounds.  Family  and  past  history  negative. 
Indefinite  onset  of  diabetes  in  February,  191(5.  Sugar  first  discov- 
ered March  12,  191(5,  and  three  days  later  the  urine  contained  (5 
per  cent.;  albumin  was  reported  absent.  The  patient  came  under 
my  observation  for  the  first,  time  on  March  is,  191(5.  During  the 
preceding  twenty-four  hours  he  had  been  fasted  except  for  one  ounce 
of  whisky  in  three  ounces  of  black  coffee,  which  he  had  taken  every 

1  Martin  and   Mason:  Am.  Jour.   Mod.  $<•.,   1017.  eliii,  p.  .">(). 

-  Kpstein  and  A-rhaar:  Jour.  Am.  Mod.  Assn.,  I'.lKi,  Ixvi,  p.   HI2'.). 

3  Kpstoin  and  Maohr:  Jour.  Mini.  ('horn..   MM  1,  xviii,  p.  21. 

4  Kpstoin:  I'mo.  Soc.  Kxpt.  Mini.  Mod.,   101(1,  xiii,  p.  (17. 

6  Myers  and  Bailey:  Jour.  Hiol.  ('hem.,   1011),  xxiv,  p.   117. 
B  HuwlburK:  Cited  Jour.  Am.   Mod.  Assn.,   1012,  lix,  p.   17/32. 


II YPERGL  YCEMIA  89 

two  hours!  Xo  other  liquid  was  given  save  about  a  pint  of  water 
in  which  a  tablespoonful  and  a  half  of  sodium  bicarbonate  had  been 
dissolved.  I  Hiring  this  period  he  had  vomited  fluid  which  contained 
blood.  He  was  dull,  but  conscious,  and  there  was  no  hyperpnea. 
Xo  edema.  He  had  no  fever;  pulse  104;  arteries  not  sclerotic.  The 
systolic  blood-pressure  in  the  right  arm  was  00  mm.  mercury,  in 
the  left  arm  SO  mm.  mercury,  and  the  diastolic  pressure  in  the 
left  arm  50  mm.  mercury  (Tycos  apparatus).  These  observations 
were  controlled  by  another  physician.  The  heart  was  little  if  any 
enlarged,  and  there  was  a  systolic  murmur  at  the  apex.  The  liver 
was  2  cm.  behnv  the  costal  margin.  During  the  twenty-four  hours, 
30  c.c.  of  urine  were  obtained  by  catheter,  showing  a  slight  trace 
of  albumin,  no  diacetic  acid,  and  a  positive  reaction  for  sugar. 
The  sediment  contained  many  coarsely  and  finely  granular  hyaline 
casts,  pus,  and  six  to  eight  red  blood  corpuscles  to  a  field.  Death 
was  preceded  by  edema  of  the  lungs  and  coma,  although  in  nowise 
suggesting  diabetic  coma.  The  blood  sugar  taken  twelve  hours 
before  death,  showed  by  the  Bang  method,  1.15,  1.45,  and  1.49 
per  cent,  of  sugar,  or  an  average  of  1.37  per  cent.  The  accuracy 
of  the  solutions  used  in  the  test  was  immediately  controlled  with  a 
standard  solution  of  glucose. 

Estimations  of  the  blood  sugar  are  undoubtedly  of  considerable 
value  in  the  treatment  of  diabetes,  but  it  is  certain  that  such  inves- 
tigations will  be  made  in  but  a  very  small  proportion  of  the  cases 
for  some  years  to  come.  To  promote  a  better  understanding  of  the 
subject,  an  attempt  has  been  made  in  the  following  tables  to  correlate 
the  blood-sugar  analyses  with  the  age  of  the  patient,  the  duration 
of  the  disease,  the  urinary  analyses,  the  carbohydrate  tolerance  of 
the  patient,  and  to  give  the  first  and  last  observation  of  the  blood- 
sugar  in  a  series  of  cases.  In  a  former  edition,  I  arranged  all  the 
cases  upon  which  blood  examinations  had  been  made  in  clinical 
groups,  absolutely  independent  of  the  results  of  the  blood-sugar 
analyses,  but  in  this  edition  I  purposely  omit  the  long  tables  and 
instead  will  give  the  conclusions  derived  therefrom. 

The  method  of  Ivar  Bang  (see  p.  204)  was  employed  in  the 
earlier  analyses,  but  the  Lewis-Benedict  method  since  the  spring 
of  1910.  Unless  otherwise  stated,  the  blood  was  taken  in  the  post- 
absorptive  state,  fourteen  hours  after  a  meal,  usually  between  seven 
and  nine  o'clock  in  the  morning. 

The  influence  of  age  upon  the  sugar  in  the  blood  of  diabetic 
patients  is  shown  in  Table  46.  In  general  the  younger  the  patient 
the  lower  the  blood  sugar,  but  the  converse  is  not  true,  and  indeed, 
for  the  sixth  and  seventh  decade,  the  values  were  nearer  those  of 
early  childhood.  Cases  Xos.  1 192, 1224,  1231  and  1200,  all  under  the 
age  of  ten,  showed  respectively,  0.06,  0.04,  0.08  and  0.07  per  cent. 


90       FACTOR*  IX   TREATMENT  OF  DIABETES  MELLITUR 

of  sugar  within  a  few  days  of  the  beginning  of  treatment.  Their 
course  in  the  hospital  was  by  no  means  as  favorable  as  such  low 
percentages  would  imply.  Their  future  behavior  will  be  watched 
with  much  interest. 

TAHI.F.    4(5. — THE    IXFLVKNTK  OF  Aci:  ri'ox  THE  BLOOD  SUCAR  i.\    DIAUKTF.S. 

A«e  of  patients,  Cases,          Analyses,  lilood  sufiar.  per  cent. 


years. 

No. 

No. 

Lowest. 

Average. 

Highest. 

o-  5 

3 

3 

0.  1(5 

0.  1(55 

0.  17 

(5-10       .      .      . 

.       8 

20 

0  .  07 

0.20 

0.33 

11-15       .       .      . 

.      1(5 

43 

0  .  07 

0.19 

0  .  45 

10-20       .      .      . 

7 

13 

0.13 

0.23 

0  .  34 

21-30       .      .      . 

.     27 

131 

0.10 

0.24 

0  .  57 

31-40 

28 

145 

0.09 

0  23 

0  39 

41-50       .      .      . 

.       IS 

53 

0.09 

0  .  22 

0.47 

51-00 

35 

67 

0  09 

0  20 

0.3S 

61-70       .      .      . 

.     is 

44 

0.12 

0.21 

0  .  45 

71  and  over 

2 

3 

0.20 

0  .  27 

0  .  36 

The  duration  of  the  disease  does  not  necessarily  boar  any  relation 
to  the  percentage  of  sugar  in  the  blood.  This  welcome  fact  is  clearly 
brought  out  by  Table  47  and  is  in  striking  contrast  to  impressions 
which  are  current  in  the  literature.  The  blood-sugar  analyses  made 
upon  my  patients  therefore  give  no  support  to  the  theory  that 
diabetes  becomes  more  severe  the  longer  it  lasts. 

TABU;  47. — Tin:   I\FLrK\a-:  OF  TIIF.  DURATION-  OF  TIIK   DISKASE  ri>o\ 
TIIE  BLOOD  SrciAR  i\  DIABETES. 


Duration  of  disease', 
years. 

I'mlrr  1          .      . 
1-2       .       .       . 
2     3 

Cases, 
No. 

.      54 
32 
23 

Analyses, 
No. 

141 
120 

70 

Bl. 

Lowest. 

0.09 
0.07 
0   10 

3-  4       .      .      . 
4-  5      .      .      . 
5-10      .      .      . 
10-15       .      .      . 
15-29 

.      14 
.      12 
.      2(5 
.      12 

i 

31 
37 
81 
19 

2(5 

0.12 

0.  10 
0.09 
0.  11 
0.09 

The  presence  of  sugar  in  the  urine  Muring  the  preceding  twenty- 
four  hours)  is  almost  invariably  accompanied  by  an  increase  of 
sugar  in  the  blood.  Among  207  of  my  blood-sugar  analyses,  there 
were  only  5  instances  in  which  this  did  not  occur.  On  the  other 
hand,  the  sugar  in  the  blood  may  be  as  high  as  ()..">()  per  cent, 
without  glycosuria. 

The  cases  in  which  there  was  glycosuria  without  an  accompanying 
hyperglycemia  were  as  follows:  Cases  Xos.  50M,  70(1,  1171,  1224  and 
12(>0. 

In  Table  4S  is  shown  the  range  of  the  percentage  of  blood  sugar 
in  my  cases  and  the  quantity  of  sugar  excreted  in  the  urine  in  the 
preceding  twenty-four  hours. 


HYPERGLYCEMIA  91 

TABLE  48. — THE  BLOOD  SUGAR  IN  RELATION  TO  THE  TOTAL  QUANTITY 
GLUCOSE  EXCRETED  IN  THE  PRECEDING  T\VENTY-FOUH  IIoi'IlS. 

Excretion  of  filucosp  in 


preceding  24  lirs., 

Cases, 

Analyses, 

Blow 

1  sugar,  per  ( 

•cut. 

grains. 

No. 

No. 

Lowest. 

Average. 

Highest. 

o 

135 

321 

0.07 

0.19 

0  .  50 

1-    5  .      . 

.      .      41 

62 

0.11 

0  .  24 

0  .  50 

<>-  10  .      . 

.      .      19 

29 

0  .  09 

0.24 

0  .  35 

11-  20  .      . 

.      .      27 

38 

0.18 

0.28 

0  .  50 

21-  30  .      . 

.      .      18 

22 

0.15 

0.2G 

0.43 

31-  50  -      . 

.      .      18 

25 

0.19 

0  .  24 

0.45 

51-  70  .      . 

.      .      11 

12 

0.11 

0.28 

0.45 

71-100  .      . 

.      .       8 

9 

0.24 

0.32 

0.40 

101-150  .      . 

.      .       6 

6 

0.19 

0.31 

0.38 

151-200  .      . 

.      .        1 

1 

0.13 

0.13 

0.13 

318    .      .      . 

.      .        1 

1 

0  .  25 

0  .  25 

0.25 

From  the  above,  it  is  evident  that  one  can  hardly  speak  of  a 
renal  threshold  in  diabetes.  Various  writers  have  suggested  different 
levels  for  normal  individuals. 

Just  what  the  threshold  is  at  which  sugar  passes  out  from  the 
blood  through  the  kidneys  into  the  urine  is  not  known.  Ilamman 
and  Hirschman  at  the  1910  meeting  of  the  American  Society  for 
the  Advancement  of  Clinical  Investigation  reported  from  a  study 
of  50  cases  that  if  the  blood  sugar  was  not  above  0.17  per  cent., 
sugar  failed  to  appear  in  the  urine,  but  that  when  it  reached  0.18 
per  cent,  or  more  there  was  a  development  of  glycosuria.  Foster 
at  the  same  meeting,  found  the  renal  threshold  of  permeability  to 
lie  between  0.149  and  0.1 64  percent.,  basing  his  observations  upon 
studies  made  with  patients  after  undergoing  ether  narcosis.  He 
also  pointed  out  that  blood  sugar  values  between  0.25  and  0.35 
per  cent.,  frequently  occurred  without  glycosuria  in  patients  with 
a  long  history  of  diabetes  usually  in  the  presence  of  renal  disease. 
Woodyatt  likewise  discussed  the  question  and  reported  that  the 
threshold  could  be  lowered  somewhat  by  diuretics  and  raised  by 
antidiuretics.  Acids  tend  to  raise  the  threshold  and  neutral  salts 
in  diuretic  concentration  to  lower  it. 

A  study  of  a  series  of  my  cases  has  shown  an  intimate  relation 
between  the  blood  sugar  and  the  carbohydrate  balance.  Thus  a 
blood  sugar  of  0.44  per  cent,  was  found  both  when  the  carbo- 
hydrate balance  for  the  preceding  day  was  —41  and  +1,  and  on 
the  other  hand  with  a  blood  sugar  of  0.11  the  carbohydrate  balance 
varied  between  —52  and  +45.  The  variable  diet  of  the  patients 
accounts  for  these  differences  in  part,  but  the  quantity  of  stored 
carbohydrate  must  also  be  important. 

In  order  to  arrive  at  some  conclusion  as  to  whether  the  percentage 
of  sugar  in  the  blood  would  give  a  clue  to  the  character  of  the  disease, 
I  have  classified  cases  upon  which  blood  examinations  have  been 
made  into  clinical  groups  wholly  independent  of  the  results  of  the 


02       FACTOR*   IX    T  If  E  ATM  EXT  OF   DIABETES   MELLITUS 

blood-sugar  analyses.  In  each  instance  the  case  number,  agent 
onset,  duration  of  the  disease  at,  the  time  the  analysis  was  made, 
the  percentage  of  sugar  in  the  blood,  the  quantity  of  sugar  in  the 
urine,  or  the  length  of  time  during  which  the  urine  has  been  sugar- 
free,  the  condition  of  the  kidneys  as  shown  by  examinations  of  the 
urine  and  the  blood-pressure,  and,  so  far  as  possible,  the  record 
of  the  diet  for  the  preceding  day  were  recorded.  r\  he  results  of  a 
critical  analysis  of  these  data  are  herewith  reported.  It.  is  striking 
to  note  that  among  a  group  of  seven  clinically  very  mild  diabetics, 
of  the  two  who  sho\ved  a  percentage  below  0.11,  each  presented 
higher  values  subsequently  rind  not  a  case  in  the  group  could  be 
classed  as  renal  diabetes.  For  example,  Case  No.  70,  with  0.24  per- 
cent, of  sugar  in  the  blood,  has  been  under  my  observation  for  twelve 
years,  during  which  period  the  percentage  of  sugar  in  the  urine  has 
never  risen  above  2.(>,  although  the  diet  lias  invariably  been  liberal. 
The  higher  percentage  of  blood  sugar  in  this  patient  is  in  marked 
contrast  to  Case  Xo.  1007,  who  suggested  at  the  first  observation  a 
moderately  severe  type  of  diabetes  of  sixteen  years'  standing,  yet 
whose  blood  sugar  was  0.1")  per  cent.  Cases  Xos.  ',}'.}],  !>!)2  and 
")().'),  who  showed  0. 1(1,  0.1(5  and  0.00  to  0.1 0  percentages  respectively, 
all  were  of  the  familial  or  hereditary  type.  Case  No.  T.SO  showed 
only  0.07  per  cent,  of  sugar  in  the  blood  on  November  2!),  1  !)!.">, 
but  on  March  10,  1!)1<>  this  had  risen  to  0.1S  per  cent.  This  case 
was  that  of  a  Harvard  student,  who  made'  the  interesting  observa- 
tion that  despite  a  liberal  carbohydrate  meal  at  noon  no  sugar 
appeared  in  the  urine  if  he  exercised  strenuously  immediately 
thereafter.  The  diabetes  of  Case  No.  So."),  with  0.1(5  per  cent,  was 
discovered  by  life  insurance  examination,  and  he  repeatedly  showed 
traces  of  sugar.  ( 'ase  No.  *,)  IS,  blood  sugar  0.11,  was  obese,  and  the 
urine  never  contained  more  than  a  trace  of  sugar. 

A  closer  relation  between  the  percentage  of  sugar  in  the  blood  and 
the  severity  of  the  disease'  became  apparent  when  the  cases  of  long 
duration  were  collected  and  divided  into  those  with  low  and  those 
\vith  a  distinctly  high  tolerance  for  carbohydrate.  (Table  4S, 
1st  Kdition.)  The  average  percentage  of  sugar  in  the  blood  of  the 
1 ")  patients  with  a  tolerance  for  only  20  grams  or  under,  as  deter- 
mined by  thirty-seven  tests,  was  0.2)!.  The  average  percentage  of 
sugar  in  the  blood  of  S  patients  whose  tolerance  was  distinctly 
high,  as  determined  by  eleven  tests,  was  0.1*.  It  is  evident  that, 
as  a  rule,  the  lower  the  tolerance  the  higher  the  percentage  of  blood 
sugar,  and  il  is  also  evident  that  when  the  tolerance  is  distinctly 
high  the  blood  sugar  is  but  little  above  normal,  although  there  are 
exceptions.  Case  No.  S.~>7  showed  0.2  per  cent,  of  blood  sugar,  and 
the  urine  contained  neither  albumin,  casts  nor  sugar,  but  the  blood- 
pressure  rose  to  2  10  at  one  time  and  the  diet  was  only  slight  lycst  noted. 


HYPERGLYCEMIA  93 

It  is  significant  that  among  the  cases  of  long  duration  it  was  not 
the  rule  for  the  blood  sugar  to  be  particularly  high,  no  matter 
whether  the  tolerance  for  carbohydrate  was  low  or  high.  ]t  was  the 
exception  for  the  blood-pressure  to  have  risen  to  an  abnormal  degree; 
furthermore,  it  is  also  interesting  that,  even  in  the  presence  of  a 
high  blood-pressure,  frequently  the  sugar  in  the  blood  Avas  not  high. 
The  average  percentage  of  sugar  in  the  blood  of  29  patients  with 
severe  diabetes  as  determined  by  one  hundred  and  eleven  tests 
was  0.21]. 

It  is  rather  striking  that  the  percentage  of  sugar  in  the  blood  in 
only  one  of  nine  children  (Case  Xo.  7S5)  was  particularly  high. 

Among  these  clinically  severe  cases  in  adults,  there  were  two 
whose  low  blood  sugars — 0.13  and  0.11  respectively — were  excep- 
tions to  the  rule.  Case  Xo.  5(54  represented  a  severe  type  of  diabetes, 
although  ultimately  becoming  sugar-free,  and  now  has  remained 
so  for  a  period  of  two  years.  Case  Xo.  70(5,  it  is  true,  represents  a 
serious  form  of  diabetes,  but  in  spite  of  this  fact  he  eventually  became 
sugar-free  and  at  the  present  writing  has  remained  so  for  five  and  a 
half  months.  The  blood  sugar  indicated  better  than  the  clinical 
impression  the  true  nature  of  the  case. 

Repeatedly  severe  cases  of  diabetes  take  an  extremely  favorable 
course  and  ultimately  prove  to  be  mild.  One  would  expect  that 
these  cases  would  show  a  particularly  low  percentage  of  blood 
sugar.  Such,  however,  is  not  the  fact,  for  in  many  instances  in  my 
series  the  blood  sugar  was  high  even  though  the  patient  was  sugar- 
free.  On  the  other  hand,  cases  classed  clinically  as  severe,  but 
becoming  mild  with  treatment,  occasionally  give  an  indication  of 
this  in  the  blood  sugar.  The  average  percentage  of  blood  sugar  of 
10  such  patients,  as  determined  by  twenty-three  observations,  was 
0.20.  Of  three  moderate  cases  which  ultimately  became  mild,  the 
average  percentage  of  blood  sugar  as  determined  by  four  observations 
was  0.1(5. 

The  following  table  (Table  49)  shows  a  series  of  simultaneous 
analyses  of  the  blood  and  urine  made  upon  different  patients  during 
the  course  of  treatment.  The  table  is  divided  into  two  parts:  the 
first  comprises  the  cases  which  are  still  alive,  and  the  second  is  made 
up  of  fatal  cases.  It  will  be  seen  that,  as  a  rule,  treatment  is  accom- 
panied by  diminution  of  blood  sugar.  It  is  probable  that  the  fall  of 
blood  sugar  would  have  appeared  more  marked  had  the  blood  been 
secured  upon  the  first  day  when  the  patient  came  under  observation 
when  sugar  was  abundant  in  the  urine.  With  the  earlier  patients 
this  was  seldom  the  case,  as  is  evidenced  by  the  fact  that  the  urine 
was  usually  sugar-free  at  both  the  time  of  the  first  and  last  blood 
tests.  It  is  of  interest  to  compare  the  earlier  figures  in  the  table 
with  those  later  obtained  with  other  patients.  It  seems  remarkable 


TABLE  49. — -ANALYSES  OF  BLOOD    SUGAR   MADE  UPON    DIABETIC   PATIENTS 
DURING  THE  COURSE  OF  TREATMENT. 


Case       •* 
No.        ° 

ge  at      Dura- 
nsct,         tion, 
ears.         yrs. 

Blood 

per 

sugar, 
•cut. 

Time  intervening 
between  tests. 

Total  sugar  in  urine  during 
24°  preceding  the  time 
of  blood  analyses,  gins. 

First. 

Last. 

First. 

Last. 

430 

20            0.7 

0  .  25 

0  .  25 

62  days 

Slight 

0 

479 

35          5.0 

0  .  33 

0.  19 

25      " 

138 

0 

oil 

43         12.0 

0.20 

0.10 

150      " 

0 

0 

C32 

30          3.0 

0  .  20 

0.21 

50      " 

0 

0 

786 

38          2  .  7 

0.27 

0.18 

28      " 

36 

0 

814 

12           0.3 

0.20 

0.29 

13  months 

0 

0 

934 

14           1.2 

0.18 

0.11 

9  days 

0 

0 

948 

30           0.1 

0.11 

0.10 

61       " 

0 

0 

951 

30          3.0 

0.  13 

0.22 

28      " 

0 

0  (1.3t  visit) 

4.0 

0  .  20 

0.15 

14      " 

0 

0  (2J  visit) 

960 

52         10.0 

0.17 

0.10 

24      " 

0 

0 

965 

40           3.5 

0.17 

0.  10 

2      " 

0 

0 

909 

42      •     0.0 

0  .  20 

0.21 

13      " 

0 

0  (1st  visit) 

7.0 

0.33 

0.22 

9      " 

40 

4  (2d  visit' 

970 

58      i     0.1 

0.10 

0.  12 

13      " 

0 

0 

979 

33         10.5 

0  .  20 

0.24 

33      " 

26 

0 

981 

28     ,      1.7 

0.20 

0  .  22 

13      " 

0 

0 

9s2 

19      ,     2.0 

0.10 

0.10 

35      " 

0 

0 

983 

55    ;    0.2 

0.38 

0.  18 

13      " 

123 

0 

991 

04           0.7 

0.20 

0.17 

29      " 

0 

0 

994 

15      !     2.1 

0.  18 

0.13 

9      " 

0 

0 

995 

0      !     0.2 

0.  19 

0  .  20 

22      " 

0 

0 

1001 

12     I      1.2 

0  .  30 

0.21 

13      " 

54 

0 

1008 

40        14.0 

0  .  35 

0.20 

41       " 

40 

0 

1011 

25          1.8 

0  .  32 

0  .  24 

45      " 

Trace 

0  (1st  visit) 

2  .2 

0.27 

0.25 

IS      " 

0 

0  (2d  visit) 

i 

2.4 

0  .  34 

0.19 

13      " 

24 

0  (3:1  visit) 

1012 

13           1.1 

0.36 

0.29 

39      " 

20 

0 

1013 

43          2  .  0 

0.14 

0.24 

16      " 

7 

0 

1022 

53        10.0 

0.15 

0.20 

2      " 

0 

0 

1020 

22          0.1 

0.  19 

0.15 

24      " 

18 

0 

1028 

29           0.9 

0.25 

0  .  28 

9      " 

0 

0 

1029 

32          3.0 

0.29 

0.26 

10      " 

14 

0 

1033 

50          4  .  1 

0.27 

0  .  30 

19      " 

40 

0 

1034 

35           0.0 

0.25 

0  .  24 

40      " 

20 

13 

106(5 

3s          3  .  0 

0  .  20 

0.  19 

8       " 

0 

0 

1070 

20          0.1 

0.  13 

0.  13 

15      " 

0 

0 

1075 

43           0  .  1 

0.  18 

0.09 

26      " 

1 

0 

1070 

53           7.0 

0.13 

0.  10 

9      " 

0 

0 

1083 

53           1.0 

0.  10 

0.21 

11       " 

0 

0 

10S4 

34           0.1 

0.  Hi 

0.  15 

17      " 

0 

0 

10.SO 

00           2.9 

0.  10 

0.  17 

3  months  6  days 

(1 

0 

1090 

18        3  .  3 

0.  10 

0.  17 

9  d  iys 

0 

0 

1094 

51           2.0 

0.30 

0.  13 

30      " 

05 

0 

1097 

42           1.0 

0.27 

0.  15 

0      " 

100 

0 

109S 

10           7.1 

0.  11 

0.  14 

5 

0 

0 

1101 

52           7  .  7 

0.20 

(  )  .  2s 

28      " 

0 

11 

1  1  02 

21           4.7 

0.20 

0.  10 

51      " 

0 

0 

1103 

l(i          4.9 

0.47 

0.13 

39      " 

110 

0 

1110 

01           3.2 

0.  15 

0.24 

13      " 

0 

0.2  per  cent. 

1125 

3  1           2  .  5 

0.  is 

0  .  1  s 

25      " 

0 

0 

1130 

21            1.1 

(  »  .  25 

0.20 

19       " 

60 

0 

1131 

20          0.3 

0.  10 

0.  10 

14       " 

0 

1137 

14           0.2 

O.I1.) 

0.  15 

S5      "                               107 

0 

1145 

00           7.5 

0.  19 

0.  10 

10      "                                   2 

0 

1147 

33           2.0 

0.29 

0.17 

IS      "                                 15 

0 

1151 

3           7.0 

(  1  .  25 

(  )  .  22 

30      "                                 42 

0 

1157 

5s           (1.3 

0.45 

0.20 

;-;o     " 

08 

0 

1159 

30          2.4 

0.34 

0.29 

13      "                                 75 

0 

1  100 

25           1  .  ,s 

0.40 

0.  17 

33      " 

92 

3 

1  173 

15           0.2 

0.45 

0.11 

11       " 

15 

0 

11S1 

21           1.1 

0.57 

(  )  .  22 

20      "                               101 

0 

1182 

3S           1.4 

o.  1:5 

0.09 

i 

0 

0 

11S5 

15           0.2 

0.  10 

0.07 

5 

9 

0 

Av 

=  0.24 

0.19 

<(94) 


HYPERGLYCEMIA 


FATAL  CASES. 


95 


Case 
No. 

Age  at 
onset, 
yrs. 

Dura- 
tion, 
yrs. 

Blood  sugar, 
per  cent. 

Time  in- 
;  tervening 
between 
tests. 

Total  sugar  in  urineduring 

24°  preceding  the  time 
of  blood  analyses,  gms 

Cause  of 
death. 

First. 

Last. 

First. 

Last. 

416 

54 

8.0 

0.24 

0.22 

42  days 

0 

0 

Uright's. 

500 

06 

4.0 

0.13 

0.17 

2      " 

0 

0 

Cancer    of 

liver. 

7(55 

21 

1.0 

0.31 

0.19 

23      " 

43 

0 

Coma. 

821 

23 

1.8 

0.34 

0.17 

42      " 

54 

0 

Coma. 

904 

38 

10.0 

0.21 

0.36 

7 

o 

23 

Carbuncle, 

coma. 

942 

29 

1.2 

0.16 

0.20 

2.6r; 

0  (1st  visit) 

Coma. 

2.0 

0.29 

0.28 

40      " 

42 

0  (2d   visit) 

900 

.'59 

0.5 

0.21 

0  .  23 

30       ' 

01 

0 

Coma. 

974 

12 

0.1 

0.17 

0.17 

11 

0 

0  (1st  visit) 

Coma. 

0.7 

0.43 

0.33 

9       ' 

o~ 

4  (2d   visit) 

990 

62 

1.2 

0.33 

0  .  29 

25       ' 

10 

0 

Coma. 

1004 

44 

0.4 

0.41 

0.28 

3       ' 

+ 

+ 

Coma. 

1005 

28 

0.3 

0  .  24 

0.24 

26       ' 

13 

39 

Coma. 

1010 

05 

7.0 

0  .  30 

0.20 

2      " 

09 

25 

Coma. 

1025 

20 

1.0 

0  .  28 

0.15 

23      " 

3 

0 

Coma. 

1049 

27 

0.7 

0.20 

0.22 

18      " 

Trace 

0 

Abscess   of 

.  lung. 

1058 

38 

0.6 

0.14 

0.14 

9      " 

0 

0 

Coma. 

1085 

34 

0.5 

0.25 

0.22 

104      " 

3 

5 

Inanition. 

1120 

G 

0.7 

0.32 

0.28 

68      " 

16 

8 

Inanition. 

AY. 

=  0.26 

0.23 

that  so  many  patients  should  become  sugar-free  and  yet  the  blood 
sugar  remain  so  high.  At  first  I  thought  this  due  to  the  short  period 
of  time  intervening  between  the  first  and  last  blood  test,  but  such 
an  explanation  will  not  suffice.  It  would  seem  to  indicate  that 
rigorous  dietetic  treatment  should  be  continued  for  a  long  period 
after  the  patient  becomes  sugar-free.  Martin  and  Mason1  also 
observed  that  whereas  the  blood  sugar  usually  fell  to  normal  with 
the  fasting  treatment,  "with  gradual  increase  in  the  diet,  how- 
ever, the  blood  sugar  rose  to  an  abnormal  degree,  usually  in  the 
absence  of  glycosuria."  This  is  a  disappointment,  for  one  always 
regrets  being  obliged  to  discharge  a  patient  from  the  hospital  with  a 
normal  urine,  but  with  an  increased  blood  sugar.  Rogers2  was 
most  fortunate  with  his  27  cases,  for  at  the  time  of  their  discharge 
their  average  blood  sugar  was  0.12  per  cent.  I  must  confess  that  an 
increase  of  blood  sugar  during  treatment  causes  me  many  mis- 
givings as  to  the  policy  of  treatment  adopted  in  the  case. 

The  rise  in  blood  sugar  of  Case  Xo.  904  was  accompanied  by  the 
extensive  development  of  a  carbuncle.  On  the  other  hand,  Case 
Xo.  1004,  who  entered  the  hospital  in  beginning  coma,  showed  a 
decrease  in  blood  sugar  as  the  coma  deepened. 

Martin  and  Mason:    LMC.  cit.,  p.  88. 
-  Rogers:    Boston  Med.  and  Surg.  Jour.,  191(5,  clxxv,  p.  152. 


96       FACTORS  IX    TREATMEXT  OF   DIABETES   MELLITUS 

F.     BLOOD  LIPOIDS. 

1.  Blood  Lipoids  in  Health. —  In  the  first  edition  a  summary  of 
the  literature  with  a  statement  of  the  existing  knowledge  of  the 
blood  lipoids  was  kindly  written  for  me  by  Profesor  Ploor  of  the 
Harvard  Medical  School.  In  this  edition  1  have  drawn  freely  from 
the  earlier  article,  and  have  added  material  from  subsequent  papers 
of  Professor  Bloor,  in  many  cases  quoting  his  own  words.  The 
tables  have  been  prepared  by  my  assistant,  Dr.  Horace  Gray,  who 
is  spending  half  of  his  tiir.e  for  eight  months  in  Professor  Bloor's 
laboratory. 

Lipoids  (fat)  are  normally  present  in  blood  in  four  forms: 

1.  Glycerides  of  the  fatty  acids,  usually  oleic,  palmitic  or  stearic, 
of  which  an   example  is  triolein- 

,,OOr       •       CnHss 
C.-.H5— HOC      •      (\-Iln 

Noor    •    r1TH33 

— glyceride  of  oleic  acid  (a  compound  (ester)  of  glycerin  and  a 
fatty  acid).  These  contain  about  9o  per  cent,  of  their  weight  of 
fatty  acids. 

2.  "Lecithin" — a  compound  of  glycerin  with  two  molecules  of 
fatty  acids  and  one  molecule  of  phosphoric  acid,  which  is  in  turn 
combined  with  one  molecule  of  cholin.     The  fatty  acids  compose 
about  70  per  cent,  of  the  whole  compound,  and  the  phosphoric 
acid  about  12  per  cent.     In  addition  to  various  kinds  of  lecithin 
other  phosphatides  are  present  in  the  blood,  notably  eephalin,  which 
is  very  nearly  like  it  in  composition  and  is  determined  along  with  it. 

In  the  graphic  formula?  the  fatty  acids  are  in  black-face  letters, 
the  alcohols  (glycerin,  cholesterol  and  cholin)  in  capital  letters  and 
the  phosphoric  acid  in  italic  capital  letters. 

OUT          •          ('iTlIs-j 

C.-,H5— OOf       •       (YJI.-n 

Oleo-palmito  lecithin  contains: 
1    molecule  of  glycerin;   2  mole- 
cules of  fatty  acid  (oleic  and  pal-  NO 
mitic  acids);   1  molecule  of  phos- 
phoric acid;   1  molecule  of  cholin. 

(CHt}     -N 

HO 

.'!.  Cholesterol-  a  secondary  alcohol  belonging  to  the  terpene 
series  of  compounds  and  containing  one  double  bond, 

OH 

C^H;,/ 

CH   •   CH   :   CH, 


BLOOD  LIPOIDS 


97 


About  two-thirds  of  the  cholesterol  in  the  plasma  is  combined 
with  fatty  acids,  thus  forming  esters,  but  in  the  corpuscles  all  of  the 
cholesterol  is  free.  In  the  cholesterol  esters  the  fatty  acids  con- 
stitute about  44  per  cent,  of  the  whole  molecule. 

4.  Cholesterol  esters — combinations  of  cholesterol  with  a  fatty 
acid,  ordinarily  oleic  or  palmitic  acid.  The  formula  for  cholesterol 
oleate  is  as  follows: 

xOOCnHM 
^CH   •  CH   •  CH: 

In  a  discussion  of  the  lipoids  of  the  blood  one  usually  refers  to 
(1)  the  total  fatty  acids,  including  in  this  term  (a)  the  fatty  acids 
in  the  glycerides,  (/;)  the  fatty  acids  in  lecithin,  (<•)  the  fatty  acids 
in  the  cholesterol  esters;  (2)  lecithin;  (.'•>)  the  cholesterol  existing 
free  or  combined  with  fatty  acid,  as  a  cholesterol  ester. 

The  methods  for  determining  the  lipoids  of  the  blood  are  com- 
plicated, a  full  analysis  by  an  expert  requiring  at  present  three  or 
more  hours.  For  convenience  the  methods  devised  by  Professor 
Bloor  are  given  on  pages  207  and  20S. 

The  total  fatty  acids  represent  the  predominant  form  in  which 
fat  appears  in  the  blood,  and  normally  vary  in  the  whole  blood 
between  0.29  and  0.42  per  cent.  The  lecithin  comes  next  and  varies 
normally  between  0.2S  and  O.oo  per  cent.  Cholesterol  is  least 
abundant  and  varies  between  0.19  and  0.2")  per  cent. 

In  Table  50  are  given  Bloor's  figures  for  the  high  normal,  average 
normal  and  low  normal  values  of  total  fatty  acids,  lecithin  and 
cholesterol  in  the  whole  blood,  the  plasma  and  the  corpuscles.  It 
will  avoid  confusion  if  little  attention  is  directed  to  the  figures  for 
corpuscles,  because  their  content  of  lipoids  varies  but  slightly  in 
health  or  disease.  The  figures  for  the  plasma  vary  most  of  all,  and 
these  afford  the  best  index  of  changes  in  the  lipoids  of  the  blood. 

TABLK  50. — LIPOIDS  OF  NORMAL  BLOOD. l 
Compiled  from  tables  of  W.  R.  Bloor,  Jour.  Biol.  C'hem..  191().  xxv,  p.  5So. 


Cor-      Whole 


Per  cent,  variation 

of  hifih  above  av.  14.0  20.0  '32.0  10.0  24.0  14.0  12.0  35.0  20.0 

Highest  normal       .       0.42  0.47  0.4")  0.33  0.2(1  0.4s      0.25  0 .  :U      0.24 

Av.  (19;2  normals   .      0.37  0.39  034  0  30  021  042      0.22  0.23  0.20 

Lowest  normal        .      0.29  0.30  0.27  0.2s  0.17  0.35      0.19  0.19  0.17 
Per  cent,   variation 

of  low  below  av.  22.0  23.0  21.0  7.0  19.0  17.0  14.0  17.0  15.0 


98       FACTORS  IX    TREATMENT  OF   DIABETES   MELLITUS 

The  reasons  for  the  variations  in  the  reported  values  of  the  blood 
lipoids  in  the  past  are  due:  ( 1 )  to  the  inadequate  methods  employed ; 
(2)  the  failure  in  many  instances  to  take  into  account  the  relation 
of  the  time  the  blood  was  taken  to  the  previous  meal,  and  (3)  to  the 
probable  presence  in  the  blood  of  enzymes,  which  may  alter  or 
destroy  the  lipoids  if  the  blood  is  allowed  to  stand  for  any  consider- 
able length  of  time  after  being  drawn. 

The  analyses  above  given,  as  well  as  those  which  will  follow, 
relating  to  my  own  patients,  have  been  made  by  Professor  Bloor 
himself.  Samples  of  blood  have  invariably  been  obtained,  unless 
otherwise  specifically  stated,  in  a  postabsorptive  condition, 
eight  to  sixteen  hours  after  the  last  meal  (with  diabetics  usually 
fourteen  hours  after  the  last  meal),  and  the  analyses  have  been 
begun  not  later  than  two  hours,  and  generally  in  half  an  hour, 
from  the  time  the  samples  of  blood  were  obtained. 

The  influence  of  food  upon  the  blood  fat  is  striking,  but  as  yet 
no  test  fat  meal  has  been  adopted,  to  serve  as  a  standard  by  which 
variations  from  the  normal  can  be  detected.  Speculation  suggests 
that  as  wide  a  variation  might  exist  in  the  blood  lipoids,  after  the 
ingestion  of  fat  in  diabetes,  as  takes  place  in  the  blood  sugar  in 
diabetes  after  the  ingestion  of  carbohydrate. 

Fasting  or  narcosis  cause  an  increase  in  the  blood  lipoids,  but  this 
is  not  constant,  apparently  depending  upon  the  nutritional  con- 
dition of  the  animal,  because  in  those  instances  where  no  marked 
increase  results  this  could  be  obtained  after  a  period  of  stuffing 
with  fat  food.  However,  it  should  be  borne  in  mind  that  Ivosen- 
feld  observed  that  the  fat  mobilization  ordinarily  produced  by 
phosphorus  poisoning  in  dogs  does  not  take  place  in  starving 
animals. 

It  is  of  interest  that  the  total  fatty  acids  of  the  blood  have  been 
found  to  be  increased  in  nephritis,  pneumonia,  pregnancy  and  in 
extremely  severe  anemia  in  animals,  conditions  in  which  acid  poison- 
ing is  supposed  to  play  a  part. 

Lecithin  appears  to  be  an  intermediate  stage  in  the  metabolism 
of  fat,  and  Bloor  points  out  that  the  blood  corpuscles,  and  in  this 
instance  the  red  corpuscles,  are  the  principal  carriers,  take  up  the 
fat  from  the  plasma  and  transform  it  into  lecithin,  and  that  most, 
if  not  all,  of  the  absorbed  fat  is  so  transformed.  The  increase  of 
lecithin  in  the  blood  during  fat  absorption  suggests  that  lecithin 
is  a  stage  through  which  the  fats  must  pass  before  they  can  be 
utilized  in  metabolism.  Lecithin  has  been  found  high  in  nephritis  and 
high  values  have  been  observed  in  the  blood  corpuscles  in  leukemia, 
but  in  the  cachexia  of  carcinoma  low  values  obtain.  It  has  also 
been  reported  increased  in  experimental  conditions  in  animals, 
such  as  in  the  anemia  produced  by  continued  bleeding,  and  in 


BLOOD  LIPOIDS  99 

depanereatized  dogs.  Lecithin  is  destroyed  upon  standing  by  the 
action  of  an  esterase  in  the  corpuscles,  and  this  may  account  for 
the  low  values  occurring  in  the  literature. 

Cholesterol  is  a  relatively  well  defined  and  stable  chemical 
substance,  and  is  the  lipoid  which  can  be  most  readily  determined. 
It  does  not  appear  to  increase  in  the  blood  directly  after  feeding 
fat  alone,  according  to  recent  work,  but  is  increased  in  narcosis, 
alcoholism  and  pregnancy,  as  well  as  in  all  cases  of  jaundice,  because 
of  the  stoppage  of  one  of  its  normal  paths  of  excretion.  It  is  in- 
creased in  nephritis,  but  decreased  in  cachexia  of  various  origins. 
Cholesterol  appears  to  play  a  minor  part  in  the  phenomena  of  fat 
absorption. 

Cholesterol  and  lecithin  are  constituents  of  all  living  cells  and 
probably  constitute  most  of  the  "built  in"  or  invisible  fat  of  the 
tissues.  Both  may  be  synthetized  in  the  body.  Lecithin  probably 
takes,  an  active  part  in  fat  metabolism  and  is  the  first  stage  through 
which  the  fats  pass  in  their  utilization  by  the  organism.  The 
function  of  cholesterol  is  less  well  known.  Where  the  vitality  was 
low  McCrudden  found  a  relation  between  the  severity  of  the  con- 
dition and  the  low  values  for  cholesterol  and  blood  sugar.  When 
the  patient  improved  under  treatment,  the  values  for  both  blood 
sugar  and  cholesterol  increased.  Table  59,  on  page  107,  illustrates 
the  relation  which  has  been  found  between  cholesterol  and  blood 
sugar  in  my  diabetic  cases. 

Fat  gets  into  the  blood  in  two  ways — about  GO  per  cent,  passes 
into  the  chyle  and  in  this  way  reaches  the  blood  stream,  but  the 
remainder  is  probably  absorbed  directly  by  way  of  the  intestinal 
capillaries.  Formerly  it  was  supposed  that  the  fats,  after  their 
hydrolysis  in  the  intestine,  were  resynthetized  during  their  passage 
from  the  intestinal  wall  and  passed  into  the  blood  stream  in  essen- 
tially the  form  in  which  they  were  ingested — that  is,  as  glycerides, 
and  that  alimentary  lipemia  was  due  to  nothing  more  than  the 
addition  of  these  glycerides.  Today  it  appears  more  likely  that 
instead  of  a  lipemia,  a  lipoidemia  exists,  in  that,  along  with  the 
increase  of  glycerides  of  fatty  acids,  there  is  also  an  increase  of 
lecithin  and  cholesterol.  Thus,  it  has  been  shown  that  the  fat  of 
the  chyle  has  a  somewhat  different  composition  from  that  of  the 
food  fat. 

Since  fat  persists  in  the  blood  in  starvation,  the  inference  appears 
plain  that  the  blood  is  mobilizing  fat  from  its  fat  depots  for  its 
nutritional  needs,  and  it  is  readily  conceivable  that  in  the  presence 
of  abnormal  metabolism  the  fat  of  an  obese  subject  might  be  more 
easily  drawn  upon,  and  that  the  effect  would  be  the  same  as  that 
of  ingested  fat.  For  this  reason  the  lipoids  in  the  blood  of  fat  and 
thin  people  present  an  interesting  field  for  study. 


100     I' ACTOli'S   IX    TltKATMKXT  <)!'    DIMiKTEX   MKLUTl'X 

2.  Blood  Lipoids  in  Diabetes. — Witli  an  excess  of  fat  diabetes 
begins,  and  from  an  excess  of  fat  diabetics  die.  In  !.">  per  cent,  of 
my  diabetic  cases  an  increase  of  body  fat  preceded  the  onset  of 
diabetes,  and  in  (10  per  cent,  of  my  fatal  cases  abnormalities  of  fat 
metabolism  resulting  in  acidosis  caused  death. 

Disordered  fat  metabolism  was  first  associated  with  diabetes 
when  phlebotomy  (bleeding)  \vas  common  by  the  observation  of  the 
milkiness  of  the  blood  of  diabetic  patients.  Severe  diabetes  was, 
and  is,  practically  the  only  disease  in  which  lipemia  is  frequent 
enough  to  be  of  special  significance.  The  milky  appearance  of  the 
serum  and  the  "cream"  which  arose  from  it  on  standing  indicated 
that  the  substance  producing  the  phenomena  was  fat.  When 
bleeding1  fell  into  disuse,  nothing  more  was  learned  regarding  the 
nature  of  this  fat  until  nearly  one  hundred  years  later,  in  190.'>, 
Fischer  observed  that  the  quantity  of  cholesterol  in  diabetic  blood 
was  abnormally  high,  and  this  finding  was  confirmed  by  Klemperer 
and  1  inbcr;  they  made  a  similar  observation  with  regard  to  lecithin. 

The  percentage  of  fat  reported  was  extreme,  and  in  one  case 
Klemperer  found  20  per  cent.;  figures  of  I o  to  20  per  cent,  were  not 
unusual.  Among  my  cases  there  was  but  one  of  lipemia,  and  in  this 
the  fat  amounted  to  9.4  per  cent.,  but  it  should  be  observed  that 
my  figures  are  based  almost  wholly  upon  patients  undergoing  treat- 
ment with  restriction  of  fat,  and  after  fasting  fourteen  hours.  In 
comparison  with  the  extreme  values  of  Klemperer,  the  increase  of 
0.4  per  cent,  in  Case  No.  7S(i  appears  only  moderate,  but  in  reality 
it,  represents  an  increase  of  twenty  times  the  average  normal  value. 

No  lipemia  (cloudiness  or  milkiness  of  the  plasma)  was  observed 
in  2.S  of  my  cases  while  under  treatment,  although  many  of  them 
were  clinically  severe.  In  fact,  lipemia  has  been  observed  by  Pro- 
fessor Hloor  in  only  2  cases  of  diabetes,  Case  No.  7<S(i  cited  above 
and  one  other.  Notwithstanding  this  fact,  the  lipoids  in  the  blood 
of  2(1  out  of  2(S  diabetic  patients  were  increased.  The  increase  took 
place  chiefly  in  the  plasma,  the  composition  of  the  corpuscles 
remaining  so  nearly  constant  as  to  be  disregarded.  The  increase 
in  my  cases  amounted  to  about  .")()  per  cent.,  and  took  place  in  all 
elements.  (See  Table  .")!.) 


Cor-       \\hol. 


blood. 

pilseles 

blond.    , 

|ill.-rles. 

blood. 

piiHc-lra. 

Diabetir  extremes 

.11    7i; 

,ir.  .!»:{ 

:«    r," 

.L'li      ."ill 

.17  ,l.s 

;..,      ,;,, 

.  1'.)   .1  1 

.1(1   .(>.-, 

.17    .L'l 

Diabetic  average'  :;li 

.52 

.59 

.43 

.36 

.30 

.46 

.29 

.36 

.20 

Normal  average    'J> 

Norn.  a]    extremes        . 

.37 

.39 

.34 

L'7      r> 

.30 

.21 

17    .L'ti 

.42 
.:•!.".   .'Is 

.22 
.10-  •'"> 

.23 

.20 

.17   .2-1 

BLOOD  LIPOIDS  101 

The  patient  who  showed  the  greatest  increase  of  total  fatty 
acids  in  the  plasma — save  for  lipemia — was  Case  No.  OS.'-},  who  was 
obese  and  developed  severe  acidosis  upon  restriction  of  carbohydrate 
and  only  after  eighteen  days  of  treatment  became  sugar-  and  acid- 
free. 

On  the  other  hand,  a  clinically  mild  case  may  show  considerable 
abnormality,  due  probably  to  diet,  as  in  102  St.  (p.  420,  Bloor), 
whose  increase  in  total  fatty  acids  was  00  per  cent.  His  tolerance 
for  carbohydrate  was  l.)0  grams.  Between  the  mild  and  severe 
cases  were  all  degrees  of  gradation  in  the  blood  lipoids,  but  in  general 
the  more  severe  the  diabetic  condition  the  more  marked  was  the 
abnormality  in  the  blood  lipoids. 

Next  in  importance  perhaps  to  the  absolute  increase  of  the 
blood  lipoids  was  the  fact  that  the  relations  between  the  lipoids 
were  practically  the  same  as  in  normal  individuals.  A  certain 
tendency  may,  however,  be  noted  which  is  significant  in  view  of  the 
conditions  in  lipemia — namely,  the  tendency  of  the  "total  fatty 
acids"  to  increase  out  of  proportion  to  the  other  constituents  as 

total  fattv  acids  . 

shown  bv  the  values  tor  the  relation  -       -   .  V.  in  the  plasma. 

lecithin 

The  occurrence  of  increased  amounts  of  lecithin  and  cholesterol 
has  led  to  the  belief  that  the  increase  was  due  to  degeneration  of 
tissue  cells,  setting  free  their  lipoids,  but  analyses  of  various  tissues 
have*shown  that  the  lipoid  content  of  the  tissues  in  diabetes  is  not 
abnormal.  Increased  mobilization  of  stored  fat  as  the  result  of  the 
partial  starvation  has  also  been  offered  as  an  explanation,  but  here 
again  the  evidence  does  not  bear  out  the  assumption.  In  the  first 
place,  the  stored  fat  contains  only  traces  of  "lecithin"  and  choles- 
terol, and  in  the  second  place,  though  fat  at  onset  diabetics  generally 
become  thin  later,  and  have  very  little  stored. fat;  also  even  com- 
plete starvation  does  not  necessarily  mean  increased  blood  fat. 
A  third  interpretation  considers  the  increase  due  merely  to  an 
accumulation  of  food  fat  which  the  organism  can  no  longer  burn, 
and  in  the  light  of  the  knowledge  that  in  diabetes  the  fat-burning 
mechanism  is  probably  deranged,  and  of  the  recent  discovery  that 
lecithin  and  probably  cholesterol  (as  ester)  are  steps  in  normal 
fat  metabolism,  this  seems  to  be  the  most  reasonable  explanation. 

Lecithin,  however,  except  for  lipemia,  varies  with  the  fatty  acids 
in  all  cases,  but  not  as  constantly  as  does  the  cholesterol. 

In  Case  Xo.  "NO  with  lipemia,  the  values  for  lecithin  were  not 
greatly  increased,  as  shown  by  a  comparison  with  the  lecithin  values 
in  this  same  patient  when  he  did  not  present  lipemia. 

Cholesterol  runs  parallel  with  the  total  fatty  acids  in  all  cases, 
including  lipemia.  Therefore  the  determination  of  the  cholesterol 
alone  in  the  plasma  should  give  valuable  information  regarding  the 
lipoid  content  of  the  blood  in  diabetes. 


102     FACTORS   IX    TltKATMEXT  OF   DIABETES   MELLITUS 

It  will  be  seen  that  the  normal  variations  for  lecithin  and  choles- 
terol were  so  great  as  to  overlap  the  variations  for  the  lecithin  and 
cholesterol  in  diabetic  blood.  On  the  other  hand,  the  lowest  figure 
obtainable  for  total  fatty  acids  in  diabetic  blood  was  at  the  upper 
normal  limit  for  these  acids  in  normal  blood,  but  this  held  good  only 
for  the  plasma.  The  total  fatty  acids  therefore  afford  the  surest 
indication  of  a  change  in  the  blood  lipoids. 

The  absence  of  lipemia  in  the  L'S  cases  undergoing  treatment, 
although  many  of  them  were  seven*,  is  a  striking  fact,  and  probably 
to  be  accounted  for  by  the  partial  or  complete  fasting.  Evidently 
lipemia  does  not  result  from  inanition.  The  two  eases  with  lipemia 
were  on  an  unrestricted  diet.  In  both  the  lipemia  disappeared 
when  they  were  put  on  a  fat-free  diet.  The  origin  of  the  lipemia, 
in  these'  eases  at  least,  appears  to  be  the  fat  of  the  diet,  and  a 
consideration  of  the  attendant  conditions  indicates  that  a  similar 
explanation  would  account  for  many  of  the  reported  instances  of 
lipemia  in  the  past.  The  dietary  treatment  of  diabetes  up  to  very 
recently  has  been  to  withhold  carbohydrate  and  make  up  the  caloric 
deficiency  with  protein  and  fat.  The  resulting  overwork  of  the  fat- 
burning  mechanism  would  be  expected  to  cause,  in  some  cases  at 
least,  a  partial  failure  of  the  mechanism  with  an  accumulation  of  fat 
and  its  metabolites  in  the  blood.  A  contributing  factor  is  the  lack 
of  available  carbohydrate  without  which  complete  burning  of  the 
fatty  acids  does  not  seem  to  be  possible.  The  high  lipoid  values 
where  there  is  no  lipemia  may  probably  be  regarded  as  an  earlier 
manifestation  of  the  same  partial  failure  of  the  fat  metabolism.  The 
mechanism  is  still  working  in  an  approximately  normal  manner, 
since  the  relations  between  the  lipoids  are  normal,  but  the  accumu- 
lation of  the  metabolites  has  begun.  In  the  actual  lipemia  the 
mechanism  has  fallen  behind  with  its  work  and  the  raw  materials 
have  accumulated  until  they  can  no  longer  be  carried  in  solution 
in  the  plasma.  That  even  at  this  time  all  parts  of  the  mechanism 
have  not  failed  is  evident  from  the  increase  of  cholesterol,  which 
keeps  pace  with  the  fat.  That  part  of  the  process,  however,  which 
has  to  do  with  the  formation  of  lecithin  from  fat  has  apparently 
failed,  and  it  is  possible  that  this  failure  may  be  tin*  underlying 
cause  of  ihe  lipemia.  I  nder  former  conditions  of  treatment  the 
chances  of  recovery  of  a  diabetic  with  lipemia  were  generally 
regarded  as  poor,  as  might  be  expected  if  the  above  explanation  ot 
the  cause  of  lipemia  were  true,  since  the  continued  diet  of  fat  in- 
volved the  overloading  of  an  already  failing  mechanism.  In  the 
two  cases  reported  here  the  lipemia  cleared  up  on  a  fat-free  diet, 
so  that  even  a  severe  lipemia  apparently  need  not  be  serious  il  the 
fat  of  the  diet  be  controlled.  The  importance  of  the  modification 
of  the  treatment  to  include  control  of  the  fat  of  the  diet  is  obvious. 


BLOOD  LIPOIDS 


103 


Occasionally  lipcmia  has  been  reported  in  diabetes  where  the 
blood  lipoids  were  not  sufficiently  above  normal  to  warrant  it.  As 
throwing  light  on  this  peculiarity  the  observation  was  made  several 
times  by  Bloor  that  a  clear  diabetic  plasma  would  become  milky 
on  standing  at  room  temperature  for  twenty-four  hours.  Bacterial 
action  cannot  be  excluded  but  since  no  such  change  was  found  to 
occur  in  normal  plasma  or  in  the  plasma  in  other  pathological 
conditions,  he  believes  the  development  of  the  milkiness  to  be  due 
to  an  inherent  peculiarity  ot  diabetic  blood — probably  some  unstable 
combination  which  is  broken  up  on  standing.  Since  many  of  the 
examinations  on  diabetic  blood  reported  in  the  literature  were  made 
on  samples  which  had  stood  twenty-four  hours  or  longer,  the 
development  of  the  lipemia  postmortem  was  not  unlikely. 

From  what  has  been  said  above  it  is  evident  that  as  yet  the 
significance  of  variations  in  the  total  quantity  of  the  lipoids  or  the 
difference  of  the  lipoids  in  diabetes  is  not  wholly  clear.  In  an 
attempt  to  bring  the  analyses  thus  far  made  into  relation  with 
fasting,  the  quantity  of  fat  in  the  diet  during  the  preceding  day,  the 
carbohydrate  balance,  the  influence  of  acidosis  and  coma,  as  well 
as  the  duration  of  the  disease,  the  following  tables  have  been 
compiled. 

The  effect  of  fasting  upon  the  blood  lipoids  in  diabetes  for  one  or 
two  days  respectively  is  shown  in  Table  52.  It  will  be  noted  that 
the  values  were  lower  for  the  second  than  for  the  first  day  of  fast- 
ing, but  the  cases  are  too  few  in  number  to  justify  deductions  save 
that  they  remained  above  the  normal  average. 

TABLE  52. — IXFLXJEXCE  OF  FASTIX<;  ox  BLOOD  LIPOIDS. 


Total  fatty  acids.                       Lecithin 

Cholesterol, 

Date.       Case    Days            ems.  in  100 

c.c.                   finis,  in  100 

c.c. 

gms.  in  100  e.e. 

1916. 

No.      fast- 

ing. 

Whole 

blood. 

Plasma. 

Cor- 
puscles. 

Whole 
blood. 

Plasma. 

Cor- 
puscles. 

Whole 

blood. 

Plasma-  pushes. 

Apr.   1C)  1025 

1 

0.50 

0.60 

0  .  38 

0.31 

0  .  25 

0.38 

0.22 

0  .  26 

0.17 

Feb.     2     974 

1           .61         .60 

.  62         .  35 

.24 

.41 

23 

.28 

.18 

Jan.    IS 

Si  0 

1           .  60 

.66 

.52         .47 

.42 

.52 

.40 

.57 

.22 

Feb.   10 

7G5 

1 

.60 

.70 

.48  i      .50 

.48 

.52 

.44 

.  65 

.21 

Av.  (4) 

1 

0  .  58 

0  .  64 

0.50 

0.41 

0  .  36 

0  .  46 

0  .  37 

0.44 

0  .  20 

Mar.  IS  1011 

2 

0  53 

0.66 

0  .  35 

0.41 

0.34 

0  .  50 

0.31 

0.39 

0.20 

The  influence  of  the  quantity  of  fat  in  tne  diet  during  the  pre- 
ceding twenty-four  hours  is  shown  in  Table  53.  It  will  be  noted 
that  with  the  increase  of  fat  in  the  preceding  day's  diet  of  the 
diabetics  there  was  in  general  an  increase  of  blood  fat,  but  this  did 
not  invariably  take  place.  Undoubtedly  some  other  factor  beside  the 


104     FACTORS  IN   TREATMENT  OF  DIABETES  MELIJTUS 


TAHLE  53. — INFLUEN'CE  OF  DIKTAUY  FAT  i\  PRECEDING  TWEXTY-FOUH 
Ilorus  ox  BLOOD  LiroiDs. 


Total  fattv  : 

-•ids,                         I.c 

"itliin.                               Cholesterol. 

(iins.  hit 

«nis.   in    100 

c.c.                    jrnis.  in   100  c.c.                    triiia.  in   100 

f.C. 

No.  (if 

in  diet  ot 

. 

— 

_ 

cases. 

preceding 
1M  hrs. 

Whole 

1.1  1. 

I'hisma. 

Cor-    '  Whole    .,,            :    for-    !  Whole 
puseles.    blood.    '           ia'  puseles.    blood. 

Plasma. 

Cor- 
puscles. 

12   .      . 

()' 

0.51 

0.57 

0.41     0.35     ( 

1.27      0.4.-)      0.27 

0.34 

0.20 

5   .      . 

1    20 

.01 

.74 

.4.-,        .42 

.  34         .51          .  32 

.41 

22 

f>    . 

21    -10 

.43 

.47 

.  35       .  3  i 

.23         .42         .2.") 

.28 

.20 

2    .       . 

(12   C,7 

.61 

.  i  2 

.47         .42 

.3N  1      .47         .3!) 

.50 

.28 

3    .       . 

Ofi    His 

.  53 

.02 

.41         .41 

.34         .40         .32 

.40 

.21 

fat  in  the  diet  influenced  the  lipoids  in  the  blood.  This  is  illustrated 
in  Table  f>4,  which  shows  the  influence  of  the  carbohydrate  balance 
in  the  diet  during  the  preceding  twenty-four  hours  upon  the  blood 
lipoids. 

In  reality,  this  table  shows  the  effect  on  the  lipoids  of  the  severity 
of  the  disease.  It  is  true  that  when  the  carbohydrate  balance  was 
2  to  40  grains  the  blood  fat  was  higher  than  when  the  carbohydrate 
balance  was  at  a  lower  level.  However,  the  supposition  is  undoubt- 
edly correct  that  when  the  patient  had  so  high  a  carbohydrate 
balance,  his  diet  in  the  immediate  past  contained  far  more  fat  than 
when  the  balance  was  more  restricted.  This  might  not  hold  true 
for  patients  living  upon  a  constant  diet  outside  the  hospital,  but 
in  the  hospital  where  the  endeavor  was  constantly  made  to  increase 
the  diet,  the  statement  is  correct. 

TABLE  54. — IXFU:I:.NCK  OF  ( 'AKBOHYDUATI:  BAI.AXCK  OF  PRECEDING  TWENTY- 
Forit  Horns  UPON  THE  BLOOD  LIPOIDS. 


Cholesterol, 
Kins,  in  100  r.c. 


O..V.)      O.tis      0.4!l      0.41       O.3.")      0.50      0.31       0.40      0.20 


to    -1 

5     .  1         0 

S     .  1    2(1 

0     .  20    10 


The  influence  of  acidosis  upon  the  blood  lipoids  deserves  atten- 
tion, because  it  is  from  abnormalities  in  the  fat  metabolism  that  (>0 
per  cent,  of  our  patients  die.  Table  5")  was  constructed  to  show 
this  feature,  but  it  shows  that  among  these  eases  no  uniformity 
exists. 


BLOOD   L IPO IDS 


105 


TABLE  55. — THE  RELATION  OF  ACIDOSIS  TO  THE  BLOOD  LIPOIDS  IN 

DIABETES. 


Total  fatty  acids, 

Lecithin, 

Cholesterol, 

\o    of 

Alveolar 

Kins,  in  100  P.O. 

Kins,  in  100 

P.P.                   finis,  in  100  c.c. 

air,  CO2. 

[ 

nun.  UK. 

Whole    „,                 Cor- 
blood.   A          ia'  pusclrs. 

Whole 
blood. 

Plasma. 

Cor- 
puscles. 

Whole 
blood. 

Plasma.     C<>T,' 
puscles. 

Av.  of  V 

14-24     0.55      0.01      0.4C. 

0.3S 

0.29 

0.50 

0  .  20 

0.29 

0.21 

Av.  of  41 

20           .47         .53     '    .40 

.34 

.25 

.48 

.24 

.2<S 

.19 

Av.  of  S1 

29-33    ,    .05     :    .83         .40 

.3s 

.  33 

.47         .33 

.42 

.21 

Av.  of  6 

35-41        .50        .02          41 

.39 

.32 

.  43         .  35 

.40 

.  25 

The  blood  of  two  patients  dying  iu  coma  was  examined  for  blood 
lipoids,  one  day  and  three  days  respectively,  before  death.  With 
these  patients  the  lipoids  were  by  no  means  high.  It  is  true  that  Case 
Xo.  1004  came  into  the  hospital  in  beginning  coma,  with  a  history 
of  having  retained  but  little  food  for  thirty-six  hours.  The  diabetes 
was  of  short  duration,  and  apparently  coma  developed  with  rapid 
change  of  diet  outside  the  hospital,  but  I  was  never  able  to  get 
exact  details.  (See  p.  343.)  Case  Xo.  100")  entered  the  hospital  in 
beginning  coma,  having  eaten  almost  no  food  for  three  days. 
TABLE  50. — INFLUENCE  OF  COMA  o.v  BLOOD  LIPOIDS. 


Date. 
1916. 

Case 
Xo. 

Total  fatty  acids,                      Lecithin 
Days           Kins,  in  100  c.c.                  Kins,  in  100 

Cholesterol, 

c.c.                    Kins,  in  100  c.c. 

before 
death.  Whole 
blood. 

Plasma. 

Cor-      Whole   p, 
pusolcs.   blood.   Plasma- 

Cor-      Whole 
puscles.   blood. 

Plasma. 

Cor- 
puscles. 

Feb.  29 
July  G 

10040.1      0.44 
1005    .3         .49 

0  .  43 
.  50 

0.45      0.33 
.  30         .  32 

0.18 
.25 

0.51      0.21 
.44     ,    .20 

0.18 
.30 

0.24 
.19 

Aver. 

0.2      0.40 

0.49 

0  .  40      0  .  32 

0.21 

0.47      0.23 

0.24 

0.21 

The  influence  of  the  duration  of  the  diabetes  upon  the  blood 
fat  would  seem  to  be  of  much  interest.  In  an  untreated  diabetic 
at  the  onset  of  his  disease  the  hyperglycemia  is  considerable,  and 
in  the  past  it  has  been  supposed  that  with  the  duration  of  diabetes 
the  sugar  in  the  blood  would  also  tend  to  mount.  Just  as  my  cases 
have  shown  that  the  blood  sugar  does  not  necessarily  increase  with 
the  duration  of  the  diabetes,  so  Dr.  Bloor's  figures  for  the  blood 
lipoids  of  iny  cases  show  that  they  are  uninfluenced  by  duration. 
TABLE  57. — INFLUENCE  OF  DURATION  ON  BLOOD  LIPOIDS. 


No.  of 

Duration, 

cases. 

years. 

10     . 

7     . 

Under  1 
1-  2 

20     . 

1-  8'- 

3     . 

14-10 

Total  fatty  acids, 
Kins,  in  100  c.c. 


Lecithin, 
gms.  in  100  c.e. 


-hole 

lood. 

1>las"'a-  pScles. 

Whole 
blood. 

,,,.,„„,.,       Cor-        Whole 
'ma'  puscles.    blood. 

Plasma. 

51 

)  .  57 

0  .  45 

0.34 

0.26      0.44      D.25 

0.29 

53 

.02 

.41 

.41 

.30 

.48 

.30 

.47 

53 

.01 

.43 

.39 

.  33 

.48 

.31 

.  43 

54 

.  04        .  42 

.36 

.27 

.48 

27 

.31 

Cor- 


1  Two  analyses  on  one  of  the  cases. 

2  Note  that  cases  between  1  and  2  years  are  included  in  thi.- 


100     FACTORS  IX   TREATMENT  OF  DIABETES  MELLITUS 

It  is  encouraging  that  the  blood  lipoids  bear  so  little  relation 
to  the  duration  of  the  disease,  for  this  faet  is  an  argument  against 
loss  of  tolerance  for  food  in  the  course  of  years;  another  argu- 
ment in  the  same  category  is  the  amenability  of  lipoids  to  diabetic 
treatment,  as  shown  by  Case  No.  7X(>,  p.  200. 

The  relation  of  the  blood  lipoids  to  prognosis  is  shown  in  Table  58, 
in  which  the  fatal  cases  are  grouped  together  according  to  the 
duration  of  life  subsequent  to  the  blood  analyses,  and  the  living 
cases  with  their  duration  up  to  February  1,  1917.  It  will  be  seen 
that  this  table  affords  no  basis  by  which  one  can  predict  the  out- 
come of  the  disease  from  the  condition  of  the  blood  lipoids. 

TABLE  ,58. — THE  RELATION  OF  THE  BLOOD  LIPOIDS  TO  PROGNOSIS. 


Dim 

No.  of 
Yrs. 

Total  fattv  acids, 
cms.  in  100  c.c. 

fJIUi 

Whole 
blood. 

lecithin 
.  in  100 

Plasma. 

c.c. 

Cor- 
puscles 

Cholester 
KIIIH.  in  100 

'1, 
c,.e. 

Cor- 
puscles. 

Mos    !  Whol(' 
Alos-     blood. 

Plasma. 

Cor- 
puscles. 

Whole 
blood. 

Plasma. 

Fatal. 
3      . 

4      . 
1      . 
3 

1-4    0.47 
7        .  4s 
S        .  00 

9           :          59 

0.51 
..')4 

.70 
07 

0.41 
.41 

.48 
.48 

0  .  34 
.31 
.  50 

.42 

0.23 

0.47      0.24 

0.20 

0.21 

.  23 
.48 
.37 

.  20 
.52 
.49 

.44 
.34 

.  05 
.45 

.20 
.21 
.20 

0.20 

Av.ofll   fatal 
Living.1 

cases  0.52 

0.58 

0.43 

0  .  30 

0.29     '0.47      0.28 

9  .  34 

3      . 

10      0.47 

0  .  54 

0.37 

0  .  32 

0.23 

0.43 

0.27 

0.33 

0.  19 

4      . 

11          .50 

.  57 

.41 

.30 

.29 

.43 

.2S 

.  35 

.20 

0      .         1 

0         .01 

.  75 

.40 

.  3S 

.33 

.47 

.29 

.38 

.21 

S       .    i      1 

1          .48 

.  50 

.44 

.  3!) 

.31 

.48 

.31 

.38 

.21 

Av.of21  livinjz 

cases  0  .  52 

0.00 

0.43 

0.37 

0.30 

0.40 

0  .  29 

0.37 

0.21 

The  quantity  of  cholesterol  in  the  blood  of  diabetic  patients 
has  also  been  compared  with  the  quantity  of  blood  sugar  on  the 
same  date.  The  data  found  are  shown  in  Table  59,  which  is  so 
arranged  that  the  mildest  cases  conic  first  and  the  severest  last.  It 
will  be  seen  that  in  general  the  cholesterol  and  blood-sugar  values 
stand  in  close  relation  in  the  milder  cases  of  the  disease,  but  that 
as  the  disease  advances  in  intensity  the  divergence  is  great.  The 
table  brings  out,  however,  that  the  cholesterol  tends  more  to 
increase  with  the  severity  of  the  disease  than  does  the  blood  sugar. 

:•>.  The  Metabolism  of  Fat  in  Diabetes. — When  carbohydrates 
cease  to  be  in  whole  or  in  part  metabolized  in  the  body  the  con- 
dition becomes  evident  by  the  appearance  of  sugar  in  the  urine 
and  the  symptoms  are  so  manifest  as  to  be  appreciated  by  physician 

1  Duration  until  February  1,  1917. 


BLOOD  LIPOIDS 


107 


cincl  patient  alike.  When  fat  ceases  to  he  metabolized  in  a  normal 
manner  no  striking  evidence  of  it  is  afforded,  and  both  patient  and 
doctor  continue  to  journey  along  in  innocent  oblivion  of  its  exist- 
ence, and  hence  fat  is  often  a  greater  danger  to  a  diabetic  than 
carbohydrate.  Just  as  increased  quantities  of  sugar  may  exist  in 
the  blood  without  being  burned,  so  can  increased  quantities  of  fat 
accumulate,  and  with  the  latter  as  with  the  former  it  is  possible  that 
the  mass  action  (Lusk)  of  the  increased  quantities  may  stimulate 
and  accomplish  this  combustion.  Already  Murlin  and  Riche1  have 
shown  that  fat  injected  directly  into  the  circulation  can  be  oxidized 
at  once.  Heat  production  promptly  rose  with  the  injection  of  .'•> 
per  cent,  emulsion  of  lard  oil,  and  the  respiratory  quotient  fell  as 
the  fat  became  concentrated  in  the  blood. 


TABLE  59. 


-THE  COMPARISON  OP  THE  CHOLESTEROL  AND  BLOOD  SUGAR 
IN  THE  BLOOD  OF  DIABETIC  PATIENTS. 


Case 

No.a 

Whole  blood. 
Blood  sii(iar,       Cholesterol. 

per  cent.        Kins,  in  100  e  c. 

Case 

No. 

Wh( 

Blood  su<;:ir 
per  eent. 

le  blood. 
Cholesterol. 
Kms.  in  100  e.c. 

500   . 

.        .       0.17 

0.  19 

960    . 

.      .      0.23 

0.28 

90S   . 

.      .      0.21 

0  .  23 

974    . 

.      .      0.19 

0  .  23 

1020   . 

.       .      0  .  20 

0.21 

S21    . 

.      .      0.34 

0.23 

970   . 

.       .      0.16 

0  .  25 

1029    . 

.      .      0  .  20 

0.40 

1007    . 

.      .      0.13 

0.20 

969    . 

.      .      0.21 

0  .  40 

1028   . 

.       .      0.25 

0.30 

951    . 

.       .      0.10 

0.37 

914   . 

.       .      0.18 

0.34 

810    . 

.      .      0.16 

0.40 

010    . 

.       .      0.20 

0.31 

786    . 

.      .      0.29 

0.37 

9S3   . 

.       .      0.29 

0.30 

1004    . 

.       .      0.41 

0.21 

979   . 

.      .      0.17 

0.23 

1005    . 

.      .      0.42 

0.26 

100S   . 

.      .      0.35 

0.31 

1005    . 

.       .      0.27 

0.26 

032    . 

.       .      0.17 

0.33 

705    . 

.       .      0.31 

0.44 

032   . 

.      .      0.16 

0.25 

705    . 

.       .      0.20 

0  .  35 

0:52   . 

.      .      0.19 

0.31 

705    . 

.       .      0.17 

0.44 

1025   . 

.      Lost 

0  .  22 

1011    . 

.      .      0  .  23 

0.31 

900   . 

.      .      0.24 

0.22 

990    . 

.       .      0.40 

0.26 

900   . 

.       .      0.21 

0.20 

Many  problems  are  now  ripe  for  investigation,  and  only  to  be 
solved  by  methods  of  study  of  the  respiratory  metabolism.  Nearly 
all  of  the  cases  reported  in  this  section  whose  blood  fat  has  been 
determined  have  been  investigated  also  with  the  respiratory  ap- 
paratus, and  I  trust  will  be  published  as  a  Carnegie  Publication 
before  the  end  of  the  year. 

For  the  present  I  can  do  no  better  than  to  summarize  Dr.  Allen's 
remarks  in  his  Harvey  Lecture  upon  the  metabolism  of  fat. 

Allen  points  out  "that  in  diabetic  patients  or  animals  alimentary 


108     FACTORS   I.\   T  RE  ATM  EXT  OF    DIABETES  MELLITUS 

hyperglycemia  is  more  pronounced  than  normal,  but  the  effect  on 
the  respiratory  quotient  is  less,  and  in  severe  eases  may  he  absent 
altogether,  and  this  is  one  of  the  best  evidences  of  deficient  com- 
bustion of  carbohydrate  in  diabetes.  The  case  with  fat  is  different, 
for  diabetic  patients  and  even  totally  depancreatized  dogs  always 
burn  fat  readily." 

lie  also  says  no  experiments  have  ever  indicated  any  difficulty 
on  the  part  of  the  diabetic  in  attacking  the  fat,  molecule.  Patients 
and  suitable  diabetic  animals  often  go  along  on  a  certain  level  of 
marked  hyperglycemia,  without  glycosuria,  and  evidently  burning 
some  carbohydrate.  They  seemingly  require  a  higher  "pressure" 
of  sugar  in  the  blood  in  order  to  accomplish  the  combustion  of  sugar. 
In  the  moderate  hyperglycemia  ordinarily  present  in  severely 
diabetic  patients,  Bloor  saw  evidence  of  a  similar  need  of  increased 
fat  "pressure"  in  the  blood  in  order  for  the  cells  to  burn  fat.  There 
is  opportunity  to  test  this  idea  with  respiration  experiments.  In 
contradiction  to  the  prevalent  belief  of  normal  fat  assimilation  in 
diabetes,  investigation  will  probably  show  that  a  certain  level  of 
lipemia  does  not  have  equal  metabolic  influence  in  non-diabetic 
and  in  diabetic  lipemic  conditions.  It  will  very  likely  be  found  that 
the  effect  on  the  gaseous  exchange  is  slower  and  of  less  degree  in 
diabetic  lipemia,  corresponding  to  the  known  facts  concerning 
hyperglycemia  in  the  milder  cases,  so  that  an  alimentary  lipemia  of 
2  or  '.}  per  cent,  in  a  normal  animal  may  represent  a  greater  activity 
of  fat  metabolism  than  much  higher  blood-fat  values  in  an  animal 
with  diabetic  lipemia.  Also,  it  may  be  found  that  the  metabolic 
effect  varies  among  diabetics  in  proportion  to  their  susceptibility 
to  lipemia,  and  conceivably  may  not  be  fully  normal  in  any  diabetic. 
Studies  of  this  sort  will  throw  light  on  the  ability  of  the  diabetic  to 
attack  the  fat  molecule;  they  may  help  to  show  why  fat  feeding 
seems  sometimes  neither  to  strengthen  nor  build  up  a  patient;  they 
will  indicate  what  significance  may  be  assigned  to  lipemia  in  the 
question  of  metabolism  in  diabetes;  and  by  completing  the  proof 
that  lipemia  is  due  to  deficient  assimilation  rather  than  increased 
mobilization  of  fat  (even  if  increased  mobilization  sometimes  occurs), 
they  may  contribute  an  analogy  in  support  of  the  dominant  belief 
that  the  hyperglycemia  is  primarily  due  to  deficient  assimilation 
rather  than  increased  mobilization  of  sugar. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUK  109 

G.     TOTAL  METABOLISM  IN  DIABETES  MELLITUS. 

1.  The  Varying  Metabolism  in  Severe  Diabetes. — The  total 
or  more  specifically  the  basal  or  gaseous  metabolism  of  diabetes 
attracted  the  attention  of  Pettenkofer  and  Yoit  in  1X07.  For  a 
period  of  twenty  years  thereafter  no  worker  ventured  to  take  up 
the  problem,  but  then  various  investigators  entered  the  field,  and 
in  the  last  few  years,  with  the  multiplication  of  apparatus  for 
metabolic  studies,  considerable  attention  has  been  devoted  to  it.1 

The  chief  interest  in  the  problem  has  been  afforded  by  the 
question  as  to  whether  the  metabolism  of  a  diabetic  patient  is 
less,  greater,  or  the  same  as  that  of  normal  individuals.  Whereas 
Pettenkofer  and  "\  oit  came  to  the  conclusion  from  their  researches 
that  the  diabetic  patient  gave  off  less  carbon  dioxide  and  con- 
sumed less  oxygen,  it  is  highly  probable  that  their  experiments 
hardly  justified  this  inference.  Magnus-Levy,  in  1905,  in  an  excel- 
lently conducted  study  of  4  diabetic  patients,  showed  an  increased 
consumption  of  oxygen  by  the  patient  per  kilogram  body  weight. 
A  moderate  number  of  other  investigators  obtained  results,  but 
these  were  so  divergent  in  character  that  the  question  remained 
still  an  open  one  in  190X.  The  problem  was  then  taken  up  afresh 
with  the  writer's  private  patients  in  connection  with  Professor 
Francis  G.  Benedict  of  the  Nutrition  Laboratory  of  the  Carnegie 
Institution  of  Washington,  situated  in  Boston.  For  the  most  part 
the  investigations  have  been  carried  on  in  the  course  of  the  routine 
hospital  treatment.  Professor  Benedict  and  I  felt  that  the  lack  of 
uniformity  in  the  results  of  other  observers  might  be  due  to  the 
fact  that  different  types  of  diabetes  were  studied,  and  therefore 
our  attention  was  directed  almost  entirely  to  the  metabolism  of 
severe  diabetes.  Like  so  many  problems  which  have  given  rise 
to  sharp  discussion,  it  now  appears  as  if  there  were  two  sides  to  the 
shield,  for  it  is  possible  to  show  in  the  same  diabetic  patient  that 
at  one  time  the  metabolism  is  increased  and  at  another  time  it  is 
below  the  normal.  The  story  of  the  experiments  of  Benedict  and 
myself  bring  out  this  point  very  clearly. 

Between  1908  and  1912  we  studied  the  metabolism  of  '22  severe 
diabetics  (Table  (>0).  Upon  comparing  these  individuals  with 
twenty  normal  individuals  of  approximately  the  same  size  and 
weight,  we  were  able  to  say  that  the  average  metabolism  of  the 
diabetic  group  exceeded  that  of  the  normal  group  by  from  15  to 
20  per  cent.  The  increase  in  the  consumption  of  oxygen  and  the 
increase  in  the  heat  eliminated  went  hand  in  hand.  The  increase 
in  the  excretion  of  carbon  dioxide  was  present,  though  less,  but  this 


110     FACTORS   IX    TREATMENT  OF   DIABETES   MELLITUS 


TABLK  GO. — COMPARISON  OF  TIIK  CARBON  DIOXIDIC  ELIMINATED  AND 
OXYGKN  ABSORBKD   BY   DIAHKTIC  AND  NORMAL  INDIVIDUALS 

IN     Exi'KRIMKNTS    WITHOUT    FoOD.1 

(Bed  Calorimeter  and  Respiration  Apparatus.) 


Normal. 


Subject. 

£••'?  J     !y 

—  '>~ 

T   u. 

^5    O    >' 

U 

_:5z            Subject. 

C    -f\     Ji 

a 

Severe 

kilos     cms. 

c.c. 

c.c.                                     kilos     cms.              c.c. 

c.c. 

diabetes: 

Case  A 

51.0     171 

1 

3  .  22 

4.22     A.  F.  G.           53.9     175     1 

3  .  30 

3  .  88 

10.1     171 

1 

2  .  s<) 

4.08      T.  M.  C.          48.5     100    is 

3.25 

3.80 

Case  B 

41.4     158 

5 

3.10 

4.29      Miss  J. 

43.3     157     3 

3  .  30 

3  .  74 

Miss  A.  C. 

42.0     105     2 

3  .  24 

3  .  99 

Miss  F.  \V. 

40.5     157     2 

3  .  7s 

4  .  57 

Mrs.  S.  C. 

37.4     155     2 

3  .  20 

3.77 

Case  C 

02.7     100 

6 

2.81 

4.12      H.  H.  A. 

02.2     104  31 

2.89 

3.51 

S.  A.  R. 

01.  1     105    13 

2  .  90 

3.02 

55.5     100 

7 

3.01 

4.35      Dr.  P.  H. 

55.2     104     9 

2  .  89 

3  .  55 

C.  H.  II. 

55.1     109  '  9 

3.14 

3  .  72 

Case  D 

48.  S    173 

3 

3.11 

4.19      T.  M.  C. 

48.5     100    IS 

3  .  25 

3.80 

C'ase  G 

07.1     178 

1 

3  .  22 

4.3S      M.  A.  M. 

00.0    177  54 

3.12 

3.68 

Case  II 

52.4     159 

7 

3  .  09 

4.05      Miss  B. 

52.2     158     2 

3.31 

3.91 

Case  1 

10.0     170 

1 

4  .  33 

0.03      T.  M.  C. 

48.5     100   18     3.25 

3  .  SO 

Case  .1 

52.9     171 

1 

3.48 

4.54      C.  II.  II. 

55.1     109     9     3.14 

3.72 

(  'ase  K 

59.1     180 

1 

2.84 

4.04      Dr.  S. 

58.5     181     5     2.02 

3  .  34 

55.0     ISO 

3 

3.31 

4.05      II.  F.  T. 

57.  S     179  44     2.  SO 

3  .  32 

Case  L 

03.0     183 

1 

3.44 

1.11       F.  P.  C. 

03.2     185  i  4 

2.71 

3.47 

00.5     183 

1 

3.08 

1.23      K.  II.  A.           (Hi./     1S2    10     2.U2 
,1.  R.                   00.0     1S2    13     3.01 

3  .  02 
3  .  03 

Case  X 

31.5     140 

7 

4.11 

5  .  57 

Case  () 

52.0     173 

3 

3.00 

4.24      Miss  F.             52.4     108     2     3.09 

3  .  07 

<"  'ase  P 

10.0     173 

5 

3  .  75 

5.3-1      T.  M.  C.          48.  5     100    is     3.25 

3.  SO 

Case  Q 

51.7     10s 

2 

3.30 

4.37      V.  G. 

54.3     102    19 

3  .  00 

4  .  33 

A.  F.  G. 

53.9     175      1 

3.30 

3  .  88 

Case  R 

55.3     isl 

1 

3  .  5  1 

4.90      IF  F.  T.         j  57.8     179    14      2  .  SO 

3  .  32 

(  'ase  S 

5V  0     177 

1 

2  .  01 

3.07       II.  F.  T.           57.  S     179    14 

2.  SO 

3  .  32 

C'ase  T 

51.4     180 

2 

3  .  29 

4.51       H.  F.  T.         i  57.  S     179  44 

2.80 

3  .  32 

A.  F.  G.           53.9     175      1 

3.30 

3  .  ss 

C'ase  I." 

39.5     100 

5 

3  .  80 

5.20      Miss  A.  C.       42.0     105     2 

3  .  24 

3.99 

Mi>s  I'..  W.     40.5     157     2 

3  .  78 

4.57 

Mrs.  S.  C.        37.4     155  ;   2 

3.2(1 

3.77 

Case  V 

OO.d     173 

1 

3.42 

4.72      11.  1',.  F.           00.0     173     7 

3.  19 

3  .  84 

Moderately 

severe  and 
lij-dit  diabetes 

Case  M  82.1      172     3      242     3.14      ().!•'.  M.  s5 .  s     171      2     2.41 

I'rof.  C.  S3  .0     109     3      2.40 

Case  W  59.5     Kil      2     2.75     3.77      Miss  B.  \V.      59.4      102     2     3.03 

Case  X  04. (J     170      1      2 .  s2     3.79      I).  M.  01.0     171      0     2.89 

Av.    of   mod-       2.00    3.57      Av.    of    nor-       ..          ..       ..2.09 

erately  mal        sub- 

>evere   and  jects  ! 

li^ht  cases 


TOTAL  METABOLISM  IX   DIABETES  MELLITUS          111 

could  l>e  explained  from  the  naturally  lower  excretion  of  carbon 
dioxide  which  would  occur  upon  the  fat-protein  diet  of  the  diabetics. 
As  a  reason  for  this  increase  of  metabolism  we  called  attention  to 
the  severe  acidosis  of  these  patients,  and  cited  other  experiments 
in  the  laboratory  by  Iliggins,  which  showed  that  the  metabolism 
of  a  normal  individual  with  an  artificial  acidosis  was  also  raised. 
(See  Table  61.) 

TAULE  Gl. — INFLUENCE  OF  AN  EXPERIMENTALLY  INDUCED  ACIDOSIS 
UPON  A  NORMAL  INDIVIDUAL.1 

Carbon  dioxide      Oxygen 

eliminated  absorbed 

per  miii.,  per  min.,    Respiratory     Average 
Sept.                                                                              c.c.  c.c.  quotient.      pulse-rate. 

7.  Carbohydrate-free  diet2  200  299  0. 07  84 

8.  Carbohydrate-free  diet  198  280  0.71  75 

9.  Carbohydrate-free  diet  195  272  0.72  72 

11.  Normal  diet  since  Sept.  9  noon  210  243  0.87  69 

Peabody,  Meyer  and  DuBois,3  in  a  study  of  cardiac  and  cardio- 
renal  cases,  also  noted  an  increased  metabolism  in  the  two  showing 
the  most  marked  acidosis,  but  in  two  others  with  only  a  slight 
acidosis  the  metabolism  was  also  high. 

Our  results  were  confirmed  by  Holly,  Leimdorfer,  (irafe  and  Wolf, 
but  were  interpreted  differently  by  Falta,  who  took  part  in  three 
of  the  first  experiments  and  also  by  Lusk,4  though  the  latter  acknowl- 
edged the  increase  but  considered  it  less  in  degree.  In  1914-1915 
the  subject  was  again  approached  by  us,  but  with  patients  under- 
going fasting  treatment.  The  results  obtained  were  so  at  variance 
with  our  earlier  observations  that  at  our  invitation  Dr.  DuBois, 
working  in  the  Russell  Sage  Laboratory  at  Bellevue  Hospital,  came 
to  Boston  and  discussed  these  with  us,  and  to  our  mutual  surprise 
it  was  found  that  the  observations  which  he  had  just  completed 
upon  one  of  Dr.  Allen's  patients  were  similar  to  ours  in  that  they 
showed  that  the  metabolism  of  a  severe  diabetic  patient  when  freed 
from  acidosis  changed  from  above  normal  to  below  normal,  with  a 
gradual  rise  in  respiratory  quotient.5  Whether  the  acidosis  is  the 
sole  factor  in  regulating  this  alteration  in  the  metabolism,  it  would 
be  unsafe  to  say.  It  is  true  that  coincident  with  an  acidosis  arti- 
ficially produced  in  three  normal  individuals  by  a  non-carbohydrate 
diet,  Iliggins,  Peabody  and  Fitz(i  observed  a  rise  in  the  metabolism 
as  indicated  by  the  oxygen  consumption.  However,  the  protein 
metabolism  was  also  high  and  Lusk7  inclines  to  the  belief  that 

1  Loc.  cit.,  Carnegie  Pub.,  176,  p.  127. 

2  Carbohydrate-iree  diet  begun  after  noon  meal,  September  5. 

3  Peabody,  Meyer  and  DuBois:    Arch.  Int.  Med.,  1916,  xvii,  p.  9,sO. 

4  Lusk:  Johns  Hopkins  Bull.,  1915,  xxvi,  p.  10. 

5  Allen:   Metabolic   Studies   in   Diabetes,    Now  York  St  ite   Journal   of   Medicine, 
1915,  xv,  p.  330. 

0  Higgins,  Peabody  and  Fitz:  Jour.  Med.  Research,  1910,  xxxiv,  p.  263. 
7  Lusk:  Am.  Jour.  Med.  Sc.,  1917,  cliii,  p.  40. 


112     FACTORS   IX    TREATMENT  OF   DIABETES   MELLITUS 

it  is  the  increased  protein  metabolism  rather  than  the  acidosis 
which  accounts  for  the  phenomenon. 

Since  H)12  Benedict  and  I  have  studied  the  metabolism  of  about 
77  more  cases  of  diabetes  and  we  hope  before  the  end  of  the  present 
year  to  publish  our  results.  A  most  careful  study  of  the  metabolism 
of  three  patients  with  severe  diabetes  has  also  been  made  by  Allen 
and  DuBois.1  They  found,  in  a  study  of  the  metabolism  of  these 
three  patients  with  severe  diabetes,  according  to  comparisons  of  the 
surface  area  by  the  new  "linear  formula,"  in  contradistinction  to 
those  of  weight  and  height,  that  "an  increase  of  the  basal  metab- 
olism in  severe  diabetes  is  generally  absent  or  slight.  During 
fasting  the  metabolism  fell  to  20  per'cent.  below  normal.  The  level 
of  the  metabolism  in  diabetes  is  the  resultant  of  a  number  of  forces; 
for  examr^e,  increased  destruction  of  protein  and  perhaps  other 
processes  tending  to  increase  metabolism,  and  undernutrition, 
muscular  relaxation  (as  in  prolonged  confinement  in  bed)  and 
other  possible  conditions  tending  to  diminish  metabolism.  Accord- 
ing as  one  or  the  other  of  these  groups  of  forces  predominate,  a 
higher  or  lower  metabolism  may  be  expected  in  any  individual  case 
of  diabetes,"  and  in  an  earlier  statement  occurs  this  sentence:  "The 
percentage  of  increase  may  be  fully  as  great  as  claimed  by  Benedict 
and  Joslin,  if  the  metabolism  of  diabetics  is  compared  with  that  of 
other  equally  undernourished  subjects,  or  if  the  same  patient  is  com- 
pared at  different  times  when  active  diabetes  is  present  or  absent." 

(ireeley-  has  pointed  out  the  analogy  between  the  steadily  decreas- 
ing severity  of  diabetes  as  age  progresses  and  the  decrease  in  the 
metabolism.  "  The  curve  of  basal  metabolism  coincides  exactly  with 
the  curve  of  severity  in  diabetes,  being  greatest  in  infancy  and  child- 
hood and  least  in  old  age.  The  severity  of  a  mild  case  of  diabetes 
is  at  once  increased  by  the  incidence  of  any  accident  increasing 
basal  metabolism  (fever,  infections,  goitre)." 

It  is  of  the  utmost  interest,  however,  that  these  observations 
have  been  made,  and  they  should  all'ord  Professor  Xaunyn  great 
satisfaction,  because  he  had  the  clinical  acumen  to  discern  that 
severe  cases  of  diabetes  treated  by  his  precise  and  successful  methods 
brought  the  patients  to  a  condition  where  the  metabolism  was 
below  normal,  which  he  recorded  in  the  statement  that  severe  dia- 
betics would  often  live  on  less  calories  than  the  normal  individual. 
The  clinical  importance  of  eliminating  acidosis  is  apparent,  for  until 
this  is  done  the  diabetic  patient  must  be  supplied  not  only  with  the 
food  which  a  normal  individual  would  require,  but,  in  addition,  with 
enough  to  make  up  for  calories  lost  in  the  form  of  acid  bodies  in  the 
urine,  and  probably  with  10  to  20  per  cent,  additional  because  of  his 
increased  metabolism. 

1  Allen  ;ii,d  ])uR>i-:   Arch.  Int.  Mod..  1010,  xvii.  p.  1010. 
Grocloy:    Knsiun  Mcd.  ,-md  Sur-:.  .lour..  liMii,  dxxv,  i>.  7.V3. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          113 


«  I 


-c  c 

C  d  J- 
O  be  - 


xi>     t-      •— 


CON 

t^  l~ 
'.  O)  X 

c  o 


X"       C       71       CO 

;  c  b-  :  t-  :  t-  :  t- 

co     o     o     o 


CO  O-M 

~*  -r  -H 

co  ;coco 

C  CO 


•2  -rt^^s? 

o     o  o  c  o 


_ 

•<      "2 
t-      ,2 


T  I 


o    •  -.:  — <  7)  CM    •  o  oi ' 


-r  co      •—  i.o  L.O  i.~  t^  t-^  X  i-O  L.O  •*  7 


•C  —  C-.  —  X  C-.  t^  o  C  X  t^  -^  -t  i  rt 
C1!  ^J  ^1  "N  ^^  ^H  ^H  CO  -t  CO  C>]  C-l  C^  "M  ^^ 


—  C—  t  " 
5;-—  £d  ~ 


114     FACTORS  IX   TREATMENT  OF  DIABETES  MELLITUS 

The  marked  variations  in  the  metabolism  of  diabetes  is  well  exem- 
plified by  a  ease  studied  by  (ieyelin  and  DnBois.1  A  young  man, 
aged  nineteen  years,  weight  1 7-  pounds,  began  to  grow  thin  November 
1,  191.1,  and  on  Xovember  20  weighed  about,  1.10  pounds.  Before 
he  came  to  the  authors,  carbohydrate  had  been  greatly  restricted 
and  protein  (and  presumably  fat)  much  increased,  with  resulting 
seven1  acidosis.  Between  December  7  and  11,  he  was  fasted  and 
.13  to  1 14  grams  sodium  bicarbonate  were  given  daily.  lie  was  then 
fed  (see  Table  02),  alkali  continued  and  the  metabolism  studied. 
From  the  table  it  can  be  seen  that:  (1)  the  metabolism  varied 
from  73  calories  per  hour  'Ml  calories  per  kilo  body  weight  per 
twenty-four  hours)  to  43  calories  per  hour  (23  calories  per  kilo  body 
weight  per  twenty-four  hours)  in  the  course  of  a  few  weeks;2 
(2)  that  a  dextrose-nitrogen  ratio  in  excess  of  Lusk's  3.0.1  :  1  ratio, 
was  obtained  on  three  successive  days,  to  wit:  .'5.97  :  1,  4.01  :  1, 
3.87  :  1;  (3)  that  the  nitrogen  in  the  urine  was  extreme,  being 
29. S  grams  on  the  second  day  of  fasting  and  MS. 27  grams  even  when 
99  grams  of  protein  were  ingested;  (4)  that  the  acidosis  was  extreme, 
for  the  /3-oxybutyric  acid  eliminated  amounted  on  one  day  to 
S7  grams.  The  case  is  remarkable  in  all  of  the  above  particulars 
and  will  always  remain  a  classic  in  diabetic  metabolism,  but  to  me 
it  is  far  more  interesting  from  other  points  of  view  and  my  interpre- 
tation of  it  is  as  follows:  A  fat  young  man  develops  diabetes  rather 
acutely.  Such  cases  usually  are  quickly  amenable  to  fasting  or 
preparatory  treatment  consisting  of  a  non-fat  diet  (see  Case  Xo. 
923,  Table  212)  but  if  placed  upon  a  protein-fat  diet  with  little 
carbohydrate,  as  was  this  case1,  develop  severe  acidosis  which  is  not 
easily  overcome  unless  taken  early.  Fat  patients  are  especially 
prone  to  develop  such  an  acidosis  (see  p.  .'544).  On  December 
11-12  a  diet  with  42  grams  carbohydrate,  IS  grams  protein  and 
IS  grams  fat  lowered  the  D:X  ratio.  It  is  true  the  acidosis  increased, 
but  this  may  be  explained  by  large  doses  of  sodium  bicarbonate  (?). 
At  any  rate,  when  protein  and  fat  were  increased  on  the  following 
three  days,  the  severity  of  the  case  increased  and  the  phenomenon 
noted  above  occurred.  Is  it  not  probable  that  if  fat  had  been 
decreased  in  the  diet  at  the  very  beginning  of  treatment,  acidosis 
would  have  been  avoided?  Did  not  the  sodium  bicarbonate  act 
harmfully  by  setting  free  /3-oxybntryrie  acid  which  previously 
was  innocuously  combined?  Had  not  the  case  been  intrinsically  a 
comparatively  mild  ca-e.  as  was  later  shown  by  a  toleration  of  100 
grams  carbohydrate,  and  a  youthful  individual,  death  from  coma 
must  have  resulted.  As  it  was,  the  case  survived  (a)  an  initial  nearly 
non-carbohvdrate  diet;  (/;)  the  increase  of  fat  in  the  diet  when 


1  Goyolin  ami  DuBoU:   Jour.  Am.  Mod.  A.ssn..  HUG.  Ixvi,  p.  1.582. 

2  Gophart.   Auli.    DuBoN   and   Lu-k.   Arch.    Int.   Med.,    1917,   xix,    p.  DOS.  discuss 
this  case  more  in  detail. 


TOTAL   METABOLISM  IX   DIABETES  MELLITU8          llo 

acidosis  was  well  under  way;  (V)  the  setting  free  of  enormous 
quantities  of  /3-oxybutyric  acid  through  the  use  of  alkalis,  and 
(d)  a  furuncle,  which  though  small,  undoubtedly  increased  the 
severity  of  the  case  (see  Case  No.  (ill),  p.  314),  and  recovered  when 
(1)  fat  was  eliminated  from  the  diet  and  protein  in  moderate 
quantities  given,  (2)  followed  after  two  days  by  fasting.  Was  it 
not  in  this  ease,  as  in  so  many  of  my  own  in  the  past,  though  with 
less  fortunate  terminations,  the  hand  of  man  that  made  the  diabetes 
severe,  just  as  later  the  hand  of  man  made  it  mild.  Such  cases  I 
have  seen  only  too  often  (see  Case  Xo.  47.'!,  p.  300),  but  I  do  not 
see  them  when  the  precautions  for  preparatory  treatment  described 
on  pp.  307-311  are  followed.  Though  perhaps  not  so  intended 
by  the  authors,  I  believe  no  case  on  record  presents  a  stronger 
argument  against  a  non-carbohydrate  diet  in  the  early  treatment 
of  diabetes,  the  harmfnlness  of  soda,  the  unreliability  of  an  exact 
D:X  ratio  even  in  the  hands  of  the  most  competent,  the  sudden 
disappearance  of  acidosis  when  a  little  protein  is  given  and  fat 
omitted  from  the  diet  and  finally,  that  acidosis,  brought  on  by 
restricted  carbohydrate  and  increased  fat,  can  be  readily  produced 
in  a  mild  diabetic  and  when  set  free  with  alkalis  can  change  the  mild 
type  to  that  of  the  severest  on  record. 

2.  Observations  upon  the  Respiratory  Quotient  in  Health  and 
Diabetes. — The  relation  which  the  volume  of  carbon  dioxide  pro- 
duced by  an  individual  bears  to  the  volume  of  oxygen  required  during 
the  same  interval  of  time  constitutes  his  respiratory  quotient.  This 
has  been  found  to  be  dependent  upon  the  character  of  the  material 
in  the  body  which  is  oxidized  or  burned  at  this  time.  An  exami- 
nation of  the  composition  of  the  carbohydrate  molecule  will  show 
that  it  contains  sufficient  hydrogen  to  unite  with  all  the  oxygen 
present  during  its  oxidation.  Consequently,  for  each  volume  of 
oxygen  used  in  the  oxidation  of  carbohydrate  a  volume  of  carbon 
dioxide  will  be  produced  and  the  respiratory  quotient  of  such  a 
carbohydrate  as  glucose  (C6II12O6)  will  therefore  be  1.  It  matters 
not  whether  the  oxidation  takes  place  rapidly  outside  of  the  body 
in  a  flame,  or  less  obtrusively  in  the  body  during  twenty-four 
hours.  Protein,  on  the  other  hand,  does  not  contain  sufficient 
oxygen  for  the  oxidation  of  the  hydrogen  atoms  contained  in  its 
molecule.  As  a  result,  in  the  burning  of  protein,  oxygen  must  be 
used  not  only  for  the  carbon  in  the  molecule,  but  for  the  hydrogen 
as  well.  The  denominator  of  the  fraction  is  tliib>  increased,  and 
the  final  quotient  of  protein  must  be  less  than  1  and  is  O.Sl.  The 
protein  molecule  is  made  up  of  many  component  parts  and  while 
the  respiratory  quotients  of  these  parts  vary  greatly,  yet  for  protein 
as  a  whole  the  above  quotient  (O.Sl)  holds.  With  fat  a  similar 
condition  exists  to  that  in  protein,  only  there  is  still  more  hydrogen 
present  to  require  oxygen,  so  that  the  amount  of  oxygen  necessary 


116     FACTORS  IN   TREATMENT  OF  DIABETES  MELLITUS 

for  the  combustion  of  fat  is  still  greater,  and  as  a  result  the  respira- 
tory quotient  falls  to  0.71.  The  respiratory  quotient  of  alcohol  is 
still  lower,  and  is  0.(>7.  /3-oxybutyric  acid,  which  can  be  taken 
as  the  chief  one  of  the  group  of  acid  bodies  formed  in  diabetes,  lias 
a  respiratory  quotient  of  O.S9,  diacetic  acid  of  1  and  acetone  of  0.7"), 
so  that  one  will  not  go  far  astray  to  take  O.S9  as  a  common  respira- 
tory quotient  for  these  three  acid  bodies. 

The  respiratory  quotient  of  an  individual  can  be  determined 
by  measurement  of  the  quantity  of  carbon  dioxide  exhaled  and 
the  oxygen  absorbed.  When  this  is  done  information  is  obtained 
concerning  the  character  and  total  amount  of  the  combustion 
taking  place  in  the  body.  Since  the  urinary  nitrogen  gives  us  a 
definite  idea  of  the  quantity  of  protein  metabolized,  if  we  calculate 
what  this  represents  in  terms  of  carbon  dioxide  and  oxygen,  and 
subtract  it  from  the  total  carbon  dioxide  exhaled  and  the  total 
oxygen  absorbed  we  have  left  the  combustion  derived  simply  from 
fat  and  carbohydrate.  Knowing  the  respiratory  quotient  produced 
when  fat  and  carbohydrate  are  oxidized  as  well  as  that  of  the  in- 
dividual, it  is  possible,  by  computation,  to  determine  the  share 
which  these  two  variables  have  taken  in  the  total  metabolism. 

TABLE  (13. — THK  RESPIRATORY  QUOTIENT   (K.   Q.)   OF  A  FOOD  is  OBTAINED 
BY  DIVIDING  THE   VOLUME  OF  CARBON  DIOXIDE  PRODUCED  DURINU 
ITS  OXIDATION  BY  THE  VOLUME  OF  OXYCEN  ABSORBED. 

Carbohydrate:     C6H12O6  +  6()2  =  GCO2  +  GH2O  R.  Q. 

Oxygen  is  required  for  oxidation  of  the  carl  ion  alone 
Volume   ()CO2  produced 
Volume     G()2     absorbed 
Fat:     Oxygen    required    for    carbon    and   a   large   quantity  of 

hydrogen 0.71 

Protein  occupies  an  intermediate  position O.X1 

Alcohol  (C2IIeO) O.K7 

B-oxybutyric  acid  (C4H8()3) O.X!) 

Diacetic  acid  (C4II6O3) 1.00 

Acetone  fC3II6O)         0.75 

The  respiratory  quotient  of  normal  individuals  twelve  hours 
after  a  meal  has  been  determined  by  Benedict,  Kmmes,  Roth  and 
Smith,  and  is  summarized  in  Table  (J4:1 

TABLE  G4.— RESPIRATORY  QUOTIENT  AND  TOTAL  METABOLISM  OF  NORMAL 

INDIVIDUALS  AT  REST  AT  A   PERIOD  TWELVE   HOURS  OR  MORE 

AFTER  THE  LAST  MEAL. 

Average  Calorics 

respiratory  per  kilo  per 

Individuals.  quotient.  twenty-four  hrs. 

S!)  men O.S3  2f).,5 

(IS  women O.S1  24.9 

If  the  fast  is  prolonged  the  respiratory  quotient  will  fall  because 
the  individual  is  forced  to  draw  wholly  upon  fat  and  protein  for 

1  Benedict,  Emmes,  Roth  and  Smith:    .lour.  Biol.  C'heni.,  1914,  xviii,  p.  1,'iO. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          117 

nutritive  material,  and  it  will  be  remembered  that  these  have  a 
respiratory  quotient  of  0.71  and  O.Xl  respectively,  in  comparison 
with  carbohydrate,  which  is  1 .  The  respiratory  quotients  of  the 
individual  studied  at  the  Nutrition  Laboratory1  who  fasted  for 
thirty-one  days,  are  shown  in  the  following  Tables  Go  and  06. 

TABLE  65. — THE  RESPIRATORY  QUOTIENTS  OF  A  MAN  DURING  A 
PROLONGED  FAST. 

Calories  per 
kilo,  body 

Respiratory       weight  per 
Period.  Time.  quotient.          24  hours. 

Preliminary  period     Fourth  day  before  fast  0.81  33 

Third  day  before  fast  0 . 89  32 

Second  day  before  fast  0.89  29 

First  day  before  fast  0.82  27 

Period  of  fast  .       .      Days  1-5  of  fast  0.77(av.)  29 

Days  6-31  of  fast  0.72(av.)  26 

After  period      .       .      Second  day  after  breaking  fast2  0.78 

Third  day  after  breaking  fast2  0.94 

TABLE  06. — QUANTITIES  OF  PROTEIX,  CARBOHYDRATE  AND  FAT  OXIDIZED 
BY  FASTING  MAN  AT  NUTRITION  LABORATORY.3 


Quantities  oxidized. 

Calories  per 

Respiratory  quotient. 

Carbo- 

kilo per 

Non- 

Protein, 

hydrate, 

Fat, 

twenty-four 

Period  of  fast. 

Actual. 

protein. 

gnis. 

gms. 

gins. 

hours. 

1st  day 

0 

,78 

0.76 

43 

69 

135 

30 

2d  day        .      .       . 

0 

75 

0.74 

50 

42 

142 

30 

3d  day       .      . 

0 

74 

0.74 

68 

39 

130 

29 

4th  day      .       .       . 

0 

75 

0.71 

71 

4 

136 

28 

5th  day      .      .       . 

0. 

76 

0  .  72 

63 

15 

133 

28 

6th  to  .'Ust  day  av. 

0 

72 

0  .  70 

53 

O4 

114 

26 

It  will  be  seen  that  the  respiratory  quotient  became  approxi- 
mately that  of  fat  within  six  days  and  remained  there  for  the 
balance  of  the  period;  that  it  rose  sharply  within  two  days  after 
breaking  the  fast,  and  upon  the  third  day  reached  0.94,  showing 
that  the  individual  must  have  taken  an  extraordinarily  large 
quantity  of  carbohydrate  food. 

The  respiratory  quotient  differs  little  from  that  of  normal  in- 
dividuals in  mild  cases  of  diabetes  when  the  urine  is  free  from 
sugar  and  the  carbohydrate  in  the  diet  large.  The  respiratory 
quotient  of  these  same  mild  cases  of  diabetes  will  be  lowered  by 
fasting  or  by  the  withdrawal  of  carbohydrate,  as  shown  above  in 
the  case  of  the  normal  fasting  man.  Evidence  is  thus  afforded 
that  the  limited  quantity  of  carbohydrate  in  the  diet  in  cases  of 
severe  diabetes  is  responsible  to  a  large  degree  for  the  low  respi- 
ratory quotient  which  such  patients  exhibit.  Magnus-Levy  called 

1  Benedict:  A  Study  of  Prolonged  Fasting,  Carnegie  Inst.  of  Washington,  No.  203. 

2  Twelve  hours  after  food. 

3  Determined  from  the  daily  metabolism,  the  urinary  nitrogen  and  the  calculated 
non-protein  respiratory  quotient. 

4  Actually  a  total  of  32  gms.  carb.  were  burned  during  the  sixth  to  thirteenth  day 
inclusive,  and  later  none. 


118     FACTOliX   IX    TREAT MK^T   OF   DIAfiKTKX   MKLUTVS 

attention  to  this,  and  so  have  other  observers.  It,  is  well  exempli- 
fied by  the  change  in  tlie  respiratory  quotient,  of  Case  Xo.  71  1. 
This  patient,  with  only  moderate  acidosis,  became  sugar-free  upon 
April  1C),  1914,  following  fourteen  days  of  treatment.  On  December 
)>,  11)1  1,  she  reentered  the  liospital  with  1.1  ])cr  cent,  of  sugar,  but 
under  fasting  treatment  became  sugar-free  after  the  omission  of 
four  meals.  The  respiratory  quotient  on  successive  days  is  shown 
in  Table  (>7: 

TAHLF.  07. — ILLTSTHATKIN  OF  KALI-  i\  RKSIMUATOKY  QroTiF.vr  OF  Mn.n 

DlAHKTIC.1 

Case  71  1.    I'Vmalr.   Ajic.  t  hid  y-oiti'ht  years,  nine  niontlis.   \\oitiht,  f>:>  kilos. 


f  + 

+  + 

+  + 

0 

+ 

+ 

+ 

10 

0 

0 

0 

25 

L5 

40 

45 

10 

15 

45 

GO 

7 

15 

.).) 

100 

(i 

!).-<•.    :;   .     .     . 
4    ;;   .     . 
.")    (i   . 
t;    7   . 
7s. 
10-11      . 

It  will  be  seen  that  whereas  the  respiratory  quotient  was  0.7X  on 
entrance,  due  undoubtedly  to  the  oxidation  of  some  of  the  carbo- 
hydrate ingested,  though  much  at  the  same  time  was  being  lost 
in  the  urine,  this  rapidly  decreased  to  0.7-'!  under  fasting  followed 
by  a  low  carbohydrate  diet.  Yet.  this  woman  could  not  be  con- 
sidered a  severe  case  of  diabetes.  The  quotient  was  low  simply 
because  she  was  living  almost  exclusively  upon  a  fat  protein  diet. 

The  problem  of  drawing  inferences  from  the  respiratory  quotient 
in  diabetes  is  complicated  by  the  fact  that  much  of  even  the  little 
carbohydrate  which  is  given  to  a  diabetic  patient  is  lost  in  the  urine. 
The  patient  really  approaches  the  condition  of  the  fasting  man  in 
that  he  is  living  exclusively  on  fat  aim  protein,  although  in  this 
case  not  that  of  his  own  body.  If  all  the  carbohydrate  ingested 
is  lost  in  the  urine,  his  respiratory  quotient  has  been  computed  to 
be  0.72  upon  the  assumption  that,  b~>  per  cent,  of  the  metabolism 
is  due  to  protein  and  N">  per  cent .  to  fat .  P>ut  there  are  other  com- 
plications. Occasionally  cases  of  diabetes  are  seen  where  the  sugar 
in  the  urine  exceeds  that  of  the  diet,  and  speculation  at  once  arises 
as  to  the  soum  of  this  excess  of  sugar.  Magnus-Levy  has  pointed 
out  that  if  the  sugar  in  the  urine  amounted  to  (10  grains  and  the 
protein  in  the  diet  to  100  grams,  the  additional  quantity  of  oxygen 
which  would  be  demanded  lo  form  this  amount  of  sugar  out  of 
protein  would  lower  the  respiratory  quotient  to  0.70.  The  situa 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          119 

is  still  further  complicated  by  the  presence  of  unoxidized  acid 
bodies  in  the  urine,  amounting  frequently  to  20  to  40  grains  and 
occasionally  to  GO  grains  calculated  as  /3-oxybutyrie  acid.  The 
amount  of  oxygen  consumed  in  the  formation  of  these  bodies  — 
for  (8-oxybutyric  is  far  richer  in  oxygen  than  are  protein  and 
fat — would  again  lower  the  quotient,  and  it  lias  been  calculated 
by  Magnus-Levy1  that  the  respiratory  quotient  of  a  case  of  diabetes 
presenting  GO  grams  of  sugar  in  the  urine  for  100  grams  of  protein 
in  the  diet,  and  excreting  20  grams  of  /3-oxybutyric  acid,  would  fall 
as  low  as  ().()(). 

For  convenience,  these  figures  are  summarized:  The  respiratory 
quotient  of  the  fasting  man  at  the  Nutrition  Laboratory  was  0.72. 
The  calculated  respiratory  quotient  of  a  normal  individual  who  is 
burning  15  per  cent,  protein  and  85  per  cent,  fat  is  also  0.72.  The 
theoretical  respiratory  quotient  of  a  diabetic  individual  excreting 
all  the  carbohydrate  ingested,  as  well  as  GO  grams  of  glucose  for 
each  100  grams  of  protein  in  the  diet,  is  0.70.  The  theoretical 
respiratory  quotient  of  the  diabetic  individual  excreting  GO  grams 
glucose  for  100  grams  protein  eaten  and  20  grams  /3-oxybutyric 
acid  as  well,  is  O.G9.  These  calculations  presuppose  that  the  sugar 
and  /3-oxybutyric  acid  excreted  were  formed  during  the  same 
twenty-four  hours,  but  who  knows  whether  this  is  the  case?  The 
theoretical  non-protein  respiratory  quotient  of  a  case  of  diabetes 
living  upon  fat  and  the  non-carbohydrate  part  of  the  protein 
molecule,  as  calculated  by  Lusk,  is  also  O.G9. 

TABLE  OS. — THEORETICAL  KESI>IRATORY  QUOTIENTS  (FROM  MAGNUS-LEVY). 

Respiratory 

Diet. 

Protein,  100  gin.      /  100  X  4.1  ==     410  \ 
Carl).,      f>07  gin.     \  .W  X  4.1   =  282.")  / 

Protein,  100  gin.      f  100  X  4.1   ==     410  ) 
Fat,          2">0  gni.     \  250  X  0.3  =  2325  J 

Loss  in  urine 
Sugar,  00  gin.  (.00  X  4.1    =  240) 

Sugar,  00  gin.  /  00  X    4.1   =  240  \ 

B-oxy.  acid,  20  gin.  \  20  X    4.7  ==     94  / 

Table  GS  shows  the  theoretical  respiratory  quotient,  which 
should  be  reached  under  varying  conditions  of  diet  for  a  normal 
individual,  and  the  changes  which  theoretically  are  present  under 
special  conditions  in  diabetes.  Figures  of  this  type  have  dominated 
the  discussion  of  the  metabolism  in  diabetes  from  the  start,  and 
whenever  experiments  have  not  produced  figures  comparable  with 

1  Magnus-Levy:   Ztschr.  f.  klin.  Mod.,  1905,  Ivi,  p.  S3. 


Diet.  Caloric.- 

2735 


120     FACTORS  I.\   TREATMEXT  OF  DIABETES  MELLITUS 

these  they  have  often  been  considered  erroneous.  We  are  taught 
to  believe  that  diabetic  patients  are  not  severe  unless  the  respiratory 
quotient  is  ().C>9.  It  is  questionable,  however,  whether  the  experi- 
mental data  at  our  disposal  enable  us  to  say  that  our  theories  are 
backed  up  by  the  results  which  we  obtain.  If  one  looks  over  the 
lists  of  respiratory  quotients  obtained  in  successive  periods  with 
any  variety  of  respiratory  apparatus  or  calorimeter,  he  will  be 
shocked  at  the  discrepancy  and  is  forced  to  the  belief  that  any 
argument  based  on  a  change  in  the  respiratory  quotient  of  one  point 
is  unjustifiable,  and  any  argument  which  is  based  on  a  change  in 
the  respiratory  quotient  of  two  points  really  rests  on  a  very  slender 
thread.  A  change  of  three  points  is,  however,  deserving  of  con- 
sideration, but  modesty  should  rule  in  conclusions  which  are  to 
be  drawn  from  any  given  set  of  experiments. 

The  average  respiratory  quotients  in  experiments  with  the  severe 
diabetics  without  food  which  were  studied  by  Benedict  and  myself 
during  190S  to  1912  are  given  in  Table  (>9,  and  for  comparison  other 
figures  are  also  added  which  show  the  respiratory  quotients  obtained 
by  various  other  observers: 

TABLE  09. — RESPIRATORY  QUOTIENT  IN  SEVERE  DIABETES. 

Respiratory 
Year.  Observers.  Cases,  quotient. 

1S94  Weintraud   and    Laves:      Ztsehr.    f.    physiol.          1  0.70 

('hem.,  1S94,  xix,  p.  (Mi. 
1S97  Nehring-Schnioll:  Ztst-hr.  f.  klin.  Mecl.,  1S97,         2  0.72 

xiii,  p.  f>9. 
!!»()")  Magnus-Levy:     Ztsclir.   f.   klin.   Mod.,    l'.M)r>,          2  0.71 

Ivi,  p.  Mi. 
1!)07  Mohr:      Ztsclir.   f.  exper.    Path.   u.   Thorap.,          1  0.72 

l'.i!)7,  iv,  j).  910. 
190s    1911  Benedict  arid  Josliii:    ( 'ariie-rio  I  list,  of  Wash-        19  0.73 

iiurton,    Publications    I'M   and    17(1,    1910, 

1912. 
1912  Holly:      Doutseh.   Arch.  f.   klin.   Mod.,    1912,          S  0.74 

cv.  p.  494. 
1912  Grafo    ami    Wolf:       Deutsch.    Arch.    f.    klin.  3  0.74 

Mod.,    1912.    cvii,    p.  201. 
1912    1914          Benedict  and  .Io>lin  7  0.73 


The  uniformity  of  the  respiratory  quotients  of  the  severe  diabetics 
studied  prior  to  1914  would  lead  one  to  believe  that  the  ordinary 
respiratory  quotient  of  severe  diabetes  was  ().7o.  To  our  surprise, 
in  November,  191."),  with  one  of  our  first  severe  diabetics  which 
underwent  fasting  treatment  we  noted  that  with  the  continuance 
of  the  fast  the  respiratory  quotient  had  a  tendency  to  reach  the 
neighborhood  ot'o.so.  Experiments  at  the  Russell  Sage  Laboratory, 
to  which  reference  has  already  been  made,  conducted  by  Dr. 
DuBois  upon  one  of  Dr.  Allen's  private  patients,  suggested  a  similar 


TOTAL   METABOLISM   IX   DIABETES   MELLITI'S          121 

condition.  In  other  words,  whereas  the  normal  individual  during 
a  fast  exhibits  a  respiratory  quotient  based  upon  the  combustion 
of  protein  and  fat  alone,  the  severe  diabetic  during  fasting  showed 
a  respiratory  quotient  which  could  only  be  accounted  for  by  the 
combustion  of  notable  quantities  of  material  other  than  fat  and 
protein.  That  this  material  was  not  protein  became  evident, 
because  the  amounts  of  nitrogen  in  the  urine  excreted  during  these 
periods  were  not  abnormal.  An  explanation  why  the  severe  dia- 
betic shows  no  acidosis  during  a  fast,  in  contradistinction  to  the 
normal  individual,  is  suggested  by  this  increase  in  the  respiratory 
quotient. 

Several  explanations  for  this  increase  in  the  respiratory  quotient 
of  fasting  diabetics  are  available.  During  fasting  the  diabetic  may 
be  able  to  draw  upon  sources  of  carbohydrate  in  the  body  which 
the  normal  individual  cannot.  Furthermore,  the  diabetic  has  in 
the  body  undoubtedly  more  carbohydrate  stored  than  we  have 
hitherto  supposed,  and  the  supposition  must  be  entertained  that 
the  diabetic  may  actually  have  more  carbohydrate  in  some  form 
in  the  body  than  exists  in  the  normal  individual.  A  third  supposi- 
tion for  the  increase  in  the  respiratory  quotient  is  that  considerable 
quantities  of  acid  bodies  have  accumulated  and  that  with  the 
improvement  of  the  condition  of  the  patient  during  fasting  these 
are  burned.  It  will  be  remembered  that  /3-oxybutyric,  diacetic 
acid  and  acetone  all  have  relatively  high  respiratory  quotients, 
namely:  O.S9,  1.00  and  0.75  respectively,  and  therefore  the  oxida- 
tion of  a  small  quantity  of  these  substances  would  markedly  raise 
the  respiratory  quotient.  Which  of  these  suppositions  is  correct 
will  be  eventually  known  because  of  the  improved  methods  of 
estimating  carbohydrate  and  acid  bodies  in  the  blood,  fluids  and 
tissues  of  the  body,  and  also  by  the  help  which  is  afforded  from  the 
estimation  of  the  carbon  dioxide  tension  of  the  blood.  If  the  rise  in 
respiratory  quotient  is  due  to  oxidation  of  acid  bodies  one  would 
expect  that  in  the  course  of  the  improvement  of  the  severe  diabetic, 
while  still  on  a  protein-fat  diet,  the  respiratory  quotient  would  again 
fall. 

3.  Observations  upon  the  Pulse. — Surprisingly  few  statements 
are  made  in  the  literature  upon  the  pulse-rate  of  diabetic  individuals. 
In  the  earlier  series  of  experiments  conducted  by  Benedict  and 
myself  a  cursory  examination  of  the  pulse-rate  indicated  no  marked 
difference  between  that  of  normal  individuals  and  of  diabetics. 
In  our  second  series  of  experiments,  conducted  during  1911-1912, 
however,  we  found,  upon  summarizing  our  observations  upon  the 
pulse-rate,  that  it  was  distinctly  elevated.1 

1  Carnegie  Pub.,  No.  176,  p.  86. 


122     FACTORS   I.\    TREATMEXT   OF   DIABETES   MELLITU8 

The  average  maximum  and  minimum  pulse-rates  for  t'ne  normal 
subjects  used  for  comparison  were  7f  and  ."H  respectively,  while 
for  the  diabetics  the  average  maximum  was  SI  and  the  average 
miniinnm  (>">  beats  per  minute.  In  preparing  these  tables  care  was 
taken  not  to  include  any  records  obviously  affected  by  excitement 
or  other  untoward  incident  in  connection  with  the  experiment, 
three  records  approximately  constant,  usually  being  taken  as  indicat- 
ing the  maximum  or  minimum.  The  values  given  can  therefore  be 
considered  as  representing  the  average  normal  variations  in  pulse- 
rate  to  be  expected  for  normal  individuals  under  the  conditions 
of  experimenting  as  employed  in  the  Nutrition  Laboratory,  and  for 
patients  with  severe1  diabetes.  It  will  be  seen,  therefore,  that  both 
the  minimum  and  maximum  pulse-rates  of  normal  individuals  are 
markedly  lower  than  those  of  diabetics. 

TAHI.K   70.  —  PCI.SK-IIATK  or   DIAHKTIC  Srn.iK(Ts. 


I )  .     52 

(':  .                                 .          09 

II  .       .                    64 

I  .       .       .           117 

J  ,       .              .      00 

K  .       .      7:? 

L  .       .      .->4 

M  01 


\imiim. 

Subject. 

Minii) 

KG 

x 

-• 

72 

o      .     . 

•  >i 

S4 

p     .     . 

f>- 

5S 

Q      • 

<>] 

74 

H       .       . 

6J 

90 

s 

5^ 

122 

T       .       . 

6: 

S4 

r     .     . 

-• 

S3 

v     .     . 

.     .    (••>: 

73 

\Y      ,       . 

9( 

M) 

X 

7- 

SI 


It.  must  furthermore  be  remembered  that  in  practically  every 
instance  the  normal  individual  led  a  much  more  active  life,  had 
much  greater  muscular  tune,  and  was  more  restless  than  were  the 
diabetics.  This  makes  the  difference  in  pulse-rate  all  the  more 


TOTAL   METABOLISM   IX   DIABETES   MELLITCS  123 

striking,  since  one  would  ordinarily  expect  a  somewhat  higher  value 
with  the  more  active  and  restless  normal  subjects  than  with,  the 
weak,  sick  diabetics,  disinclined  t:>  any  extraneous  muscular  motion. 
An  examination  of  Tables  70  and  71  shows  no  regularity  in  either 
the  minimum  or  maximum  pulse-rates  when  individual  diabetics 
are  compared  with  normal  individuals,  since  some  of  the  diabetic 
subjects  show  a  minimum  pulse-rate  considerably  lower  than  the 
average"  minimum  pulse-rate  of  the  normal  subjects;  and  similarly, 
the  normal  individuals  in  some  instances  show  a  pulse-rate  con- 
siderably higher  than  the  average  maximum  pulse-rates  of  the 
diabetics.  On  the  whole,  however,  a  distinct  tendency  toward  an 
increased  pulse-rate  in  diabetics  is  here  clearly  shown.  This  increase 
is  fully  in  conformity  with  the  increased  metabolism  which  was 
noted  with  these  severe  diabetics.  Yet  in  this  discussion  of  the 
pulse-rate  it  should  be  stated  that  it  is  questionable  whether  suffi- 
cient information  with  regard  to  normal  pulse-rate  has  accumulated 
to  indicate  that  a  variation  of  15  per  cent,  above  normal  could  be 
recognized.  While  the  metabolism  may  be  15  per  cent,  above 
normal  and  be  accurately  measured,  since  normal  metabolism  is 
fairly  well  established,  a  15  per  cent,  increase  in  the  pulse-rate  could 
not  be  so  easily  identified.  The  intimate  relationship  between 
pulse-rate  and  metabolism  in  resting  subjects  is  evident  in  nearly 
every  new  publication  on  metabolism  and  shows  that  today  the 
pulse-rate  is  taking  on  a  new  significance;  it  is  not  at  all  impossible 
that  the  degree  of  aeidosis  and  the  degree  of  metabolism  may  be  at 
least  approximately  estimated  in  diabetics  by  a  careful  examination 
of  the  pulse-rate.  The  attention  of  the  physician  i.s  directed  to  the 
importance  of  the  pulse-rate  in  diabetes  and  particularly  to  the 
value  of  changes  in  the  pulse-rate  in  the  same  patient  during  the 
progress  of  the  disease.  The  practice  first  established  by  Prout  of 
reporting  the  pulse-rate  with  the  chemical  data  of  each  experiment 
is  recommended  to  all  experimenters.  It  is  hoped  that  physicians 
will  study  this  question  further.  Of  course  a  few  observations 
upon  the  pulse-rate  during  the  twenty-four  hours  would  be  of  little 
value,  because  these  are  so  easily  affected  by  extraneous  causes. 
To  be  of  value  the  observations  should  be  at  frequent  intervals 
of  the  day  and  several  counts  should  be  taken  in  succession.  For 
example,  it  was  not  uncommon  in  our  experiments  for  the  pulse 
to  be  counted  forty  times  in  a  single  experiment.  The  count  was 
made1  with  the  use  of  a  stethoscope  which  the  patient  wore  during 
the  whole  period,  and  the  observations  were  made  without  the 
patient  knowing  when  they  were  being  obtained. 

4.  Observations  upon  the  Weight. — Edema.— -Perhaps  no  one 
gross  observation  made  during  the  course  of  diabetes  mcllitus  is  of 
greater  significance  and  causes  greater  alarm,  both  to  patient  and 


124     FACTORS   7.V    TREATMENT   OF   DIABETES   MELLITUK 

to  the  physician,  than  the  persistent  loss  in  body  weight.  On  the 
other  hand,  slight  changes  in  body  weight  which  may  accompany 
dietetic  alterations  or  the  ingestion  of  sodium  chloride  and  sodium 
bicarbonate  are  looked  upon  as  material  gains  and  are  thus  liable 
to  be  misunderstood  by  the  patient.  To  interpret  intelligently 
these  changes,  it  is  necessary  both  for  the  physician  and  for  the 
patient  to  realize  the  factors  affecting  the  body  weight  of  normal 
as  well  as  pathological  cases.  Few  realize  that  the  normal  individual 
is  continually  undergoing  changes  in  body  weight  throughout  the 
twenty-four  hours.  Even  during  sleep  it  has  been  shown  that  a 
man  of  85  kilos  loses  30  grams  per  hour,  and  a  woman  of  05  kilos 
20  grams  per  hour.  With  exercise  this  is,  of  course,  greatly  increased, 
and  may  amount  to  0.4  kilos  for  a  foot-ball  player  during  one  hour 
and  fifteen  minutes  of  active  exercise. 

Edema  is  a  common  source  of  error  and  it  is  important  to  recognize 
it  as  a  cause  of  gain  in  weight  in  diabetes.  Patients  may  seem  to  be 
gaining  when  in  reality  they  are  losing  weight  because  of  insufficient 
diet.  The  edema  occurred  most  frequently  in  former  years  following 
oatmeal  clays  and  the  administration  of  alkalis,  but  now  is  common 
with  fasting  diabetics  of  severe  type  and  is  apparently  related  to  the 
large  quantity  of  salt  which  they  ingest  with  broths  and  vegetables. 

The  edema  may  become  extreme  and  one  of  my  patients  (Case 
Xo.  922),  whom  1  had  not  seen  for  months,  called  in  a  laryngologist 
and  barely  escaped  tracheotomy  for  edema  of  the  larynx.  This 
quickly  disappeared  with  the  omission  of  salt  and  a  diet  of  water 
and  a  few  oranges.  The  patient  later  entered  the  hospital,  became 
sugar-free  and  developed  a  tolerance  for  49  grams  carbohydrate, 
09  grams  protein  and  143  grams  fat. 

Diabetic  patients  should  be  weighed,  preferably  naked,  before 
breakfast,  and  after  the  urine  has  been  voided,  for  a  patient  fre- 
quently voids  a  pound  at  a  time.  The  average  weight  of  clothes  of 
men  and  women  falls  between  8  and  10  pounds.  Women's  clothes 
weigh  approximately  2  pounds  less  than  the  clothes  of  men.  The 
table  of  height  and  weight  for  normal  men  and  women  with  clothing 
and  for  diabetic  patients  will  be  found  on  page  55,  and  on  page  50 
is  given  the  height  and  weight  of  children  between  the  years  of 
one  and  fifteen. 

(a)  Water  Content  of  the  Body. — A  factor  which  should  be  taken  into 
consideration  in  interpreting  changes  in  body  weight  is  the  fluctua- 
tion in  the  water  content  of  the  body.  It  should  be  realized  that  the 
average  man  at  rest  without  food  oxidizes  per  day  about  75  grains 
of  protein,  25  grains  of  glycogen  and  200  grams  of  fat — a  total 
of  300  grams  of  water-free,  organized  body  tissue.  It  can  readily 
be  seen,  therefore,  that  with  the  subjects  at  rest,  large  and  rapid 
changes  in  weight  must  be  due  not  to  the  oxidation  of  organic 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          125 

material,  which  amounts  to  only  300  grams  per  day,  but  to  large 
excretions  of  water.  Under  certain  conditions  it  is  possible  for  the 
body  to  retain  considerable  quantities  of  water,  and  conversely,  to 
be  deprived  of  considerable  amounts  of  water  that  would  normally 
be  retained.  Since  about  00  per  cent,  of  the  body  is  water,  any 
change  of  water  content  may  result  in  material  gains  or  losses  in 
body  weight.  A  man,  weighing,  for  example,  05  kilos,  may  have 
an  absolute  water  content  of  39  kilos,  so  that  a  relatively  small 
change  in  the  percentage  of  water  in  the  body  may  produce  a 
change  in  body  weight  of  1  kilo. 

(6)  Influence  of  Fat  and  Carbohydrate  Diets  upon  Weight. — Remark- 
able changes  in  the  weight  of  normal  individuals  will  also  occur,  if 
the  proportion  of  fat  to  carbohydrate  is  altered,  although  the  caloric 
value  of  the  diet  remains  constant.  A  diet  rich  in  carbohydrate 
brings  about  an  increase  in  weight,  whereas  a  diet  of  exactly  the 
same  number  of  calories,  though  chiefly  made  up  of  fat,  lowers  the 
weight.  These  changes  undoubtedly  are  due  simply  to  the  retention 
of  water  by  the  tissues  upon  a  carbohydrate  diet  and  loss  of  water 
upon  a  fat  diet.  Such  changes  appear  reasonable  because  the 
storage  of  1  gram  carbohydrate  in  the  body  demands  the  retention 
of  3  grams  of  water,1  1  gram  of  protein  would  appear  to  require 
the  same  amount,  and  1  gram  of  fat  requires  only  0.1  gram  of 
water.  These  changes  are  well  illustrated  by  the  following  table : 

TABLE  72. — CHANGES  IN  WEIGHT  WITH  FAT  AND  CARBOHYDRATE  DIETS. 
CARBOHYDRATE  DiET.2 

Food  and  drink.  Body  Gain  ( +) 

Solid  matter,       Water,  Total  weight,  or  loss  (— ), 

Date,  1904.  gms.  gms.  gms.  kg.  gms. 

Apr.  16 .  .  ..  75.086 

16-17   .      .     970  3577  4547  75.443  +357 

17-18   .      .     966  3553  4519  75.414  -  29 

18-19   .      .     966  3491  4457  75.269  -145 

FAT  DIET. 

Apr.  19-20  .  .  750  3108  3859  74.319  -950 

20-21  .  .  745  4150  4896  73.480  -839 

21-22  .  .  747  4152  4899  72.528  -952 

Average  gain  per  day,  carbohydrate  diet,  +61  gms. 

Average  loss  per  day,  fat  diet,  —914  gins. 

Water  stored  per  day,  carbohydrate  period,  +165  gms. 

Water  lost  per  day,  fat  period,  —906  gms. 

It  is  important  to  bear  in  mind  the  effect  upon  weight  which 
must  occur  when  a  carbohydrate-free  diet  is  prescribed,  for  other- 
wise the  loss  of  the  few  pounds  which  is  bound  to  ensue  might  cause 
undue  apprehension  or  be  interpreted  as  loss  of  tissue. 

'Zuntz:    Biochem.  Ztschr.,   1912,  xliv,  p.  290. 
2  Carnegie  Pub.  No.  176,  p.  93. 


126     I' ACTORS   J.\    TREAT. ME  XT  OP   DIABETES   MELLITUS 

An  increase  in  weight  following  a  marked  increase  of  carbohydrate 
in  the  diet  is  strikingly  illustrated  in  severe  diabetic  patients  under 
the  oatmeal  treatment.  I  nder  these  conditions  the  weight  may 
rise  4..")  kilos  during  one  or  two  days.  It  is  not  uncommon  to  observe 
that  edema  develops  during  the  course  of  an  oatmeal  cure.  It  is 
significant  that  some  of  these  cases  show  little  or  no  carbohydrate 
in  the  urine.  There  will  probably  be  general  agreement  to  the 
statement  that  the  gain  in  weight  following  the  sudden  introduction 
of  large  quantities  of  carbohydrate  is  to  be  explained  by  the  storage 
temporarily,  perhaps,  of  carbohydrate  in  the  body,  and  along  with 
this,  as  has  been  pointed  out,  marked  quantities  of  water  will  be 
retained.  That  this  storage  or  delay  of  excretion  is  accentuated 
in  the  case  of  the  presence  of  diseased  kidneys  is  common  knowledge. 
Barrenscheen1  showed  that  excretion  of  lactose  was  delayed  upon 
the  day  following  an  oatmeal  cure. 

( c]  Influence  of  Sodium  Chloride  upon  Weight. — The  quantity  of  salt 
in  the  diet  also  affects  the  weight.  For  example,  in  the  study  of  an 
individual  upon  a  salt-free  diet  consisting  of  the  whites  of  IS  eggs 
(210  calories),  120  grams  olive  oil  (10SO  caloric's)  and  200  grams 
crystallized  sugar  (SOO  calories),  total  2090  calories,  or  30  calories 
per  kilogram  body  weight,  the  weight  fell  from  70.2  kilograms  on  the 
first  day  to  (ik(.)  kilograms  on  the  thirteenth  day,  as  will  be  seen 
from  the  following  table: 

TABLE  73. — Loss  OF  WKK;HT  ('OIXCIDKNT  \vrni  A  SALT-FREE  PIF.T.- 


Day. 


1  .  . 

470 

1720 

1012 

.29 

4  .  00 

2  .   . 

550 

1810 

1010 

.29 

2  .  52 

3  .   . 

500 

1430 

1012      1 

.28 

1  .SS 

4  .   . 

290 

930 

1017      1 

.20 

O.S7 

,j 

290 

1100 

1013 

.43 

0.09 

0  .   . 

515 

1170 

1012      1 

.04 

0.48 

7  .   . 

200 

S50 

1015      1 

.  15 

0.40 

S  . 

125 

1000 

1013     ( 

).7S 

0.40 

9  . 

290 

1100 

1011      ( 

).95 

0.20 

0  .   . 

200 

800 

1015      ( 

).S9 

0  .  22 

1  .   . 

200 

050 

101S      ( 

),70 

0.22 

2 

2  1  5 

510 

1023  '    ( 

).79 

0.17 

3 

170 

500 

102:;      ( 

).80 

0.17 

ro.2 


The  subject  was  then  put  upon  a  free  diet  and  three  days  later 
the  weight  had  risen  to  OH  kilograms. 


!  Barri'ii>chciMi:  Hiorhom.  Zt.-rhr..  lit  12.  \\xix.  p.  4 ">'.). 

-  Guodall  and  ,Jn~lin:  Experiments  with  Ash-free  Diet,  Arch.  Int.  Med.,  190S,  i,  p.Glo. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS 


127 


Tf  such  notable  changes  in  weight  occur  with  normal  individuals, 
it  is  evident  that  one  must  be  extremely  cautious  in  interpreting 
changes  which  occur  in  the  weight  of  diabetic  patients.  In  illus- 
tration I  would  cite  the  gain  in  weight  which  sometimes  takes  place 
during  fasting,  due,  undoubtedly,  to  the  retention  of  water,  and 
as  1  was  able  to  demonstrate  in  Case  No.  5 18,  this  was  brought 
about  by  the  patient  having  taken  a  mineral  water  containing 
considerable  quantities  of  salt.  (See  p.  lioo.)  None  of  my  other 
patients  have  shown  such  extensive  variations  in  weight  in  so  short 
a  time  as  did  this  individual.  (See  also  Case  No.  "Go,  p.  :>14.) 

(d)  Influence  of  Sodium  Bicarbonate  upon  Weight. — The  administra- 
tion of  sodium  bicarbonate  is  frequently  followed  by  a  gain  in  weight. 
Thus,  in  Case  Xo.  220,  the  changes  in  weight  during  the  adminis- 
tration of  sodium  bicarbonate  were  as  follows: 


TABLE  74.- 


Date. 
Nov. 


-GAIN  ix  WEIGHT  COINCIDENT  WITH 
SODIUM  BICARBONATE. 

ADMINISTRATION  OF 

Sodium 
bicarbonate 
gms. 

Body 
weight, 
kilos. 

Date. 

Sodium 
bicarbonate 

gms. 

Body 

weisiht, 
kg. 

.        0 

IS  .  1 

Nov.     7    . 

.       .      20 

50  .  7 

.        0 

48.6 

8    . 

.      .      20 

51.5 

.        0 

40.0 

9    . 

.      .      20 

52.4 

.        0 

4S  .  G 

10    . 

.      .      20 

53  .  3 

.      20 

49  .  3 

11    . 

.    ..      20 

53  .  3 

Iii  order  to  show  that  this  gain  in  weight  was  not  directly  due  to 
the  alkali,  but  rather  to  retention  of  salt,  the  weights  of  another 
diabetic  patient,  Case  Xo.  135,  were  taken  while  upon  a  salt-free 
diet. 

TABLE  75. — ABSENCE  OF  GAIN  ix  WEKIIIT  COINCIDENT  WITH  ADMINIS- 
TRATION OF  SODIUM   BICARBONATE  WHEN  THE   DIET  is  SALT-FREE. 
CASE  Xo.   135. 


Diet.     Salt-free. 


Trine. 


-/     5  £    = 

7; 

—  '5 

;. 

tt 

;_ 

M   :  ~  ^ 

•^  — 

~ 

c~*     —  ^  >>    -   f~ 

^ 

*-   1  -  w 

K       tl 

0 

«_/   :  ^   -r  i  ti 

| 

-r 

° 

tt 

"~  '-'» 

-•^ 

5  s  =' 

C3 

-j   "  ti   *- 

*j 

3" 

'<-! 

_, 

~   w  -X 

c  ~ 

^--    •    — 

Q 

^  -     -  i  * 

- 

> 

* 

X    < 

cb.   -   o   -/. 

Jan.  26  I  0  135  110 

185 

3500 

3720 

21.8 

4.2 

7.9i  20  4.4  8.2  160 

27   0  135  110 

185 

3500 

3940 

19.6 

4.3 

7  .  8 

29  4.5 

6.3  165 

2s   0  135  110 

185 

3500 

3210 

20  .  5 

4.4 

7.3 

24 

4.6 

5.9  160 

29   0  135   90 

155 

3500 

3210 

19.2 

4..  1 

7.3 

26 

4.2 

4.8  163 

30 

25  135  !  70 

185 

3500 

3190 

10.3 

3.5   8.7 

33 

4.1 

1.6  146 

31 

25  120'  60 

95 

23 

5370 

4600 

19.1 

4.3  12.6 

51 

5.1 

2.3  146 

Feb.  1 

37  130  100 

130 

45 

5250 

4050 

is.  7 

3.3  10.7 

39 

4.3 

2.0  137 

o 

52   70   60 

95 

45 

5370 

3510 

16.0  3.5  10.2 

37 

3.9 

2.1  121 

3 

.  .   15  .  15 

30 

45 

800 

360 

15.0 

..   86 

128     FACTORS  IN   TREATMENT  OF  DIABETES  MELLITUS 

It  will  be  seen  that  while  upon,  the  salt-free  diet  the  weight  steadily 
fell  and,  despite  the  administration  of  sodium  bicarbonate  later,  no 
increase  in  weight  occurred.  This  observation  has  been  confirmed 
by  Levison.1  The  explanation  of  the  usual  gain  in  weight  of  diabetic; 
patients  following  the  use  of  sodium  bicarbonate  was  pointed  out 
by  Cioodall  and  Joslin2  some  years  ago.  Apparently  the  adminis- 
tration of  sodium  bicarbonate,  by  favoring  the  excretion  of  large 
quantities  of  retained  acid  bodies,  leads  to  irritation  of  the  kidneys, 
resulting  in  their  inability  to  excrete  salt  in  the  normal  manner. 
If  the  salt  in  the  diet  is  restricted,  there  is  less  to  be  retained  and 
consequently  no  gain  in  weight  results. 

Fischer3  explains  the  phenomena  in  another  way:  "Sodium 
chloride  retention  is  not  due  to  an  inability  of  the  kidneys  to  eliminate 
it,  but  to  a  change  in  the  proteins  (and  other  colloids)  of  the  body 
as  a  whole.  Sodium  chloride  retention  does  not  lead  to  edema,  but 
the  changes  which  lead  to  edema  and  to  sodium  chloride  retention 
are  the  same,  consisting,  in  the  main,  of  an  abnormal  production 
and  accumulation  of  acid  in  the  body." 

I  might  here  make  the  clinical  observation  that  a  salt-free  diet 
in  diabetes  is  inadvisable.  It  is  noteworthy  that  patients  during  the 
period  of  coma  markedly  lose  weight.  Edema,  which  may  be 
present  just  prior  to  coma,  disappears  during  coma;  in  fact,  I 
remember  to  have  seen  but  one  patient  in  coma  who  showed  edema. 

The  severe  diabetic  during  coma  utilizes  apparently  all  possible 
liquid  in  the  tissues  to  aid  in  the  excretion  of  toxic  bodies.  The 
importance  of  maintaining  sufficient  fluid  in  the  body  deserves 
emphasis.  Hodgson1  has  thoroughly  appreciated  it  for  years  and 
endeavored  to  make  his  patients  retain  large  quantities  of  fluid. 

These  remarkable  changes  in  weight  suggest  several  lines  for 
investigation:  (1)  Does  the  mere  retention  of  fluid  in  the  body 
lead  to  the  retention  of  carbohydrate?  (2)  Does  the  retention 
of  fluid  in  the  body  lead  to  a  better  utilization  of  carbohydrate? 
(•'>)  Is  the  reverse  of  these  two  propositions  true?  (4)  Might  it 
not  be  possible  by  a  series  of  experiments  designed  to  increase  the 
content  of  water  in  the  body  to  throw  light  upon  the  capacity  of 
the  body  to  store  carbohydrate?  (">)  May  not  rapid  losses  in  the 
weight  of  severe  diabetic  patients  be  an  early  guide  to  approaching 
coma? 

(e}  Weights  and  Losses  of  Weight  in  Diabetic  Patients.-  The  percent- 
age of  loss  in  body  weight  of  some  200  of  my  cases  was  computed  for 
me  by  the  Nutrition  Laboratory.  The  average  loss  previous  to  the 
first  visit  was  10  per  cent.,  and  between  this  time  and  the  last 

1  Levison:    Jour.  Am.  Mod.  Assn.,  191"),  Ixiv,  p.  .'ii'O. 

'Ibid.:    190s,  li,  p.  71' 7.  3Ihid.:    191.J,  Ixiv,  p.  325. 

•'Hodgson:    Jour.  Am.  Mod.  Assn.,  1911,  Ivii,  p.  1LS7. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          129 

observation  a  further  loss  of  3  per  cent,  occurred.    This  is  good 
evidence  that  these  cases  came  almost  uniformly  late  for  treatment. 

In  this  series  of  cases  the  highest  reported  weight  of  a  patient 
was  118.5  kilograms  and  the  lowest  13.4  kilograms. 

It  is  most  important  that  patients  should  understand  the  signifi- 
cance of  changes  in  their  body  weight,  and  should  not  be  too  much 
depressed  or  elated  by  losses  or  gains  in  the  same.  It  should  be 
explained  to  them  that  loss  of  weight  by  design  during  the  beginning 
of  treatment  is  very  different  from  a  loss  of  weight  which  occurs 
through  ignorance  while  the  disease  is  progressing  unfavorably. 

(/)  The  Loss  of  Weight  Prior  to  and  during  Coma. — The  loss  of 
weight  of  patients  immediately  prior  to  and  during  coma  has  always 
appeared  to  me  to  be  great,  but  from  the  nature  of  the  case  it  has 
been  difficult  to  determine  this  point.  A  hint  of  this  was  afforded 
by  noting  the  marked  loss  in  weight  which  occurred  in  Case  No.  135, 
from  whose  diet  salt  was  excluded,  but  a  still  better  example  was 
that  of  Case  No.  513,  already  referred  to  on  page  127,  who  lost 
35  pounds  in  the  eleven  days  preceding  the  third  day  before  death 
in  coma.  Further  observations  of  this  character  should  be  made 
for  I  doubt  not  that  they  will  show  surprisingly  large  losses  of 
weight  by  the  diabetic  individual  preceding  death  by  coma.  Too 
much  emphasis,  however,  must  not  be  laid  upon  these  data  until 
they  are  compared  with  the  data  of  non-diabetics  dying  from  a 
variety  of  causes. 

This  apparent  loss  of  weight  during  coma  has  always  interested 
me  deeply.  Obviously  it  is  due  to  a  desiccation  of  the  body,  and  in 
conformity  to  it  can  be  placed  my  experience  of  not  having  seen 
a  patient  who  has  edema  develop  coma. 

(</)  Variations  in  Weight  during  the  First  Week  of  Fasting  Treatment.— 
Sufficient  data  on  the  effect  of  fasting  upon  the  weights  of  patients 
are  not  yet  available,  but  the  results  at  hand  are  at  first  glance 
most  surprising.  When  one  considers  the  steady  loss  of  weight 
without  a  single  day's  interruption  of  the  man  who  fasted  for  thirty- 
one  days  and  was  studied  at  the  Nutrition  Laboratory,  the  contrast 
is  even  more  marked. 

In  Table  70  are  shown  the  variations  in  weight  of  70  diabetic 
patients  during  the  first  week  of  treatment,  when  they  were  either 
fasted  or  upon  a  diet  closely  approximating  a  fast.  (See  also 
Tables  147-150,  pp.  330-333.)  The  subject  is  too  large  a  one  for 
discussion  here,  but  will  be  taken  up  in  detail  in  a  forthcoming 
report  in  connection  with  the  Nutrition  Laboratory.  Suffice  it 
to  say  that  when  the  gain  in  weight  exceeded  5  pounds,  edema 
was  evident  to  the  eye,  and  the  acidosis  was  extreme.  The 
loss  of  weight  of  5  or  more  pounds  usually  indicated  either  severe 
diabetes  or  obesity. 
9 


130     FACTORS  L\    TREATMENT  OF   DIABETES   MELLITUS 

TABLE  70. — VARIATIONS  IN*  WEKHIT  OF  70  DIABETIC  PATIENTS  DURING  THE 
FIRST  WEEK  OF  TREATMENT  WITH  FASTING  OR  Low  DIET. 


Number 

Change  in  weight.                               of  rases.  Positive.  Negative. 

(lain Hi  13                       3 

Loss                                                                 51  -1(1                      8 


Pounds. 

0  to  2 


<J      M  I     ') 

3  to  1     .       . 

.     .         .     .  10 

1  to  5     .       . 

5 

598 

867 

S75 

907 

1028 

5  to  6    .      .      , 

3 

733 

785 

803 

(I  to  7     . 

,      .      .      .      .      3 

887 

895 

1038 

7 

1 

209 

GAIN  IN  W 

EIGHT. 

Number 

Pounds. 

of  cases. 

Case  No. 

0  to  2     .        .        . 

.        .        .        .        <» 

2  to  3     .      .      . 

9 

•u  . 

1 

1001 

2 

20 

2 

8 

1 

9 

598 

1 

867 

I1 

S75 

1 

007 

1 

102S 

1 

733 

P 

785 

1 

S03 

1 

SS7 

1 

895 

1 

1038 

1 

209 

1 

Acidosis. 

Absent.  Present. 

2  7 

0  2 
1 

51 1  78C,  ..  P 

7', 1  821  ..  P 

8J 1  513  ..  I4 

ll:j 1  9t)()  ..  I-1 

5.  Observations  upon  the  Nitrogen  Excretion.  (The  Dextrose- 
Nitrogen  Ratio.) — I  low  dependent  the1  nitrogen  excretion  of  diabetic 
patients  is  upon  the  diet  is  evident  when  one  notes  the  quantity 
present  in  the  urine  of  an  untreated  severe  diabetic.  Frequently 
values  of  2")  to  •'>()  grams  nitrogen  are  obtained  in  contrast  to  half 
this  quantity  for  the  normal  individual,  ruder  modern  treatment 
the  nitrogen  excretion  of  a  diabetic  patient  falls  to  the  neighbor- 
hood of  <S  to  12  grams  per  day.  'The  determination  of  the  nitrogen 
on  the  basis  of  milligrams  per  hour  per  kilogram  body  weight  was 
made  in  a  considerable  scries  of  patients  studied  at  the  Nutrition 
Laboratory  between  I!)OS  1012;  in  other  words,  several  years  prior 
to  the  inauguration  of  fasting  treatment.  The  average  value  found 
was  S.I  milligrams  nitrogen  per  kilogram  per  hour,  which  would 
amount  to  1  1.1  1  grains  urinary  nitrogen  for  an  individual  of  70  kilos, 

'-'  First  day  only. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          131 

Allowing  for  the  loss  of  nitrogen  in  the  stools,  this  would  represent 
a  protein  intake  of  about  100  grains.  This  was  in  contrast  to  a 
series  of  normal  individuals  of  approximately  the  same  size,  for 
whom  the  nitrogen  excretion  per  kilogram  per  hour  was  O.Xrngins., 
or  11.42  grams  on  the  basis  of  70  kilograms  body  weight,  or  a 
protein  intake  of  a  little  over  SO  grains. 

An  abnormal  nitrogenous  excretion  in  diabetes  has  always  seemed 
to  me  to  be  lacking,  but  my  own  case  disproves  it.  Case  Xo.  513, 
p.  353,  while  ingesting  11  grams  protein  daily,  excreted  an  average 
of  33. S  grams  nitrogen  daily  for  five  days  ending  the  second  day 
prior  to  coma.  This  patient  had  multiple  abscesses  originating  in 
a  carbuncle. 

Another  similar  case  is  that  of  Geyelin  and  DuBois,  already 
cited  on  p.  112,  who  excreted  an  average  of  33.2  grams  nitrogen 
daily  between  December  8-9  to  December  17-18  inclusive,  while 
the  average  of  the  protein  intake  during  this  period  was  44  grams 
daily.  He  had  an  infection. 

Miinzer  and  Strasser1  report  the  nitrogen  in  the  urine  of  a  man, 
fasting,  during  the  first  day  of  coma  to  be  32  grams;  the  patient 
died  the  next  day. 

Case  No.  1190  p.  379  is  remarkable  because  he  differs  from  all 
the  above  in  that  he  showed  no  acidosis,  although  he  excreted  a 
daily  average  of  25.5  grams  nitrogen  for  eight  days,  losing  much  in 
weight,  and  becoming  so  weak  as  to  be  barely  able  to  raise  his  hand. 
The  case  later  began  to  improve  and  is  described  in  full  under  the 
discussion  upon  inanition.  lie  had  no  infection. 

The  relation  between  the  excretion  of  dextrose  and  that  of  nitrogen 
—the  dextrose-nitrogen  ratio — is  considered  of  great  importance 
by  Lusk.2  :i  4  lie  has  reached  the  conclusion,  based  upon  many 
observations  upon  dogs  following  injections  of  phlorhizin  and  by 
one  case  of  diabetes  coming  under  his  personal  observation,  and 
others  selected  from  the  literature,  that  in  the  severest  diabetic  this 
dextrose-nitrogen  ratio  is  3.05  :  1.  By  this  he  means  that  when 
the  patient  is  on  an  exclusively  fat-protein  diet  3.05  grams  of  dextrose 
appear  in  the  urine  for  1  gram  of  nitrogen,  or  the  0.25  grams  of 
protein  which  it  represents.  In  other  words,  00  per  cent. — actually 
3.05  divided  by  0.25  equals  58.4 — of  the  protein  burned  by  the  body 
appears  in  the  urine  in  the  form  of  sugar.  Lusk  considers  that  this 
is  the  greatest  possible  amount  of  sugar  which  can  appear  in  the 
urine  on  a  carbohydrate-free  diet,  and  lie  assumes  that  it  comes 

1  fit.  by  C.eyelin  and  DuBois:  Loc.  cit. 

'-  Mandel  and  Lusk:    Dent.  Arch.  f.  klin.  Mod.,  1901,  Ixxxi,  p.  -170. 

3  Lusk:  Arch.  Int.  Mod.,  1909,  iii,  p.  1:  also  Harvey  Lectures.  .1.  B.  Lippincott 
Company.  Philadelphia,  100S-0,  Metabolism  and  Diabetes. 

'For  a  full  discussion  of  the  subject  see  Lusk's  forthcoming  :M  edition  of  The 
Science  of  Nutrition,  W.  B.  Saunders  Company,  Philadelphia. 


132     FACTORS  IN   TREATMENT  OF  DIABETES  MELLITUS 

wholly  from  protein.    In  a  recent  publication  he  has  collected  in  a 
table  notable  illustrations  of  such  ratios. 

TABLE  77. — I):  X  RATIOS.      (AFTKH  LUSK.) 

1'hlorhizin.  .  Diabetes  inellitus  in  man. 

In  don.  In  num. 

Mundel  and 
I.usk.      Horn-dirt,  S.   H.      I.usk.  Criimvjdd 

3.05  3.5s 

3.60  3.S2 

.3.02  3.6(5 


3.6S  3.64  3.04  3.48  3.00  3.08 

To  this  table  I  expected  to  add  other  examples  from  my  own  cases, 
but  I  am  not  able  to  do  so.  For  the  last  two  years  it  has  been 
my  custom  in  the  presence  of  acid  intoxication  to  omit  all  fat  from 
the  diet  and  to  treat  the  patient  without  alkalis.  Under  these 
circumstances  high  dextrose- nitrogen  ratios  quickly  vanish.  This 
has  led  me  to  investigate  the  conditions  under  which  the  high  dex- 
trose-nitrogen ratios  above  cited  and  also  elsewhere  reported  have 
been  found.  So  far  as  I  am  aware  no  ratio  indicative  of  complete 
diabetes  (/.  e.,  I)  :  N  =  3.05  :  1)  exists  unless  the  patient  has  re- 
cently taken  an  alkali,  usually  sodium  bicarbonate,  or  fat.  This 
observation  is  in  confirmation  of  Benedict's  and  my  experimental 
data  that  there  is  no  diabetic  so  severe  that  he  cannot  burn  some 
carbohydrate.  The  greatest  service  of  the  dextrose-nitrogen  ratio 
is  in  my  opinion  the  proof  which  it  affords  that  human  diabetes  in- 
trinsically is  not  complete.  Like  the  largest  sheet  of  water  in 
Massachusetts,  complete  human  diabetes  exists  only  by  the  hand 
of  man. 

I  can  confirm  the  statement  of  Lusk  to  this  extent,  that  no 
patient  has  come  under  my  observation  with  a  greater  dextrose- 
nitrogen  ratio  than  this,  if  one  discards  those  cases  in  which  a 
higher  ratio  might  rightly  be  interpreted  as  due  to  the  preceding 
diet.  The  embarrassing  feature  of  the  matter  is  that  this  dextrose- 
nitrogen  ratio  wholly  disappears  after  fasting,  because  then  sugar 
disappears  from  the  urine.  It  is  hard  to  understand  how  a  patient 
one  day  fails  to  burn  the  protein  of  an  ox  and  on  the  next  day  burns 
his  own  body  protein  with  ease. 

Unfortunately  one  cannot  be  sure  that  in  the  disintegration  of 
the  protein  molecule  the  nitrogen  and  carbohydrate  leave  the  body 
hand  in  hand.  As  a  rule,  the  nitrogen  loiters  behind,  greatly  to  our 
annoyance  in  estimating  the  source  of  the  sugar  in  the  urine. 
Mendel  and  Lewis'  have  recently  shown  that  this  delay  was  increased 
if  either  indigestible  substances  or  cotton-seed  oil  formed  a  prominent 

1  Mfiidcl  and  Lewi*:   Jour,  of  I3i»l.  Clu-in.,  1!H3-1'J14,  vi,  pp.  1'J,  37. 


TOTAL  METABOLISM  IN   DIABETES  MELLITUS 


133 


part  of  the  diet — just  the  sort  of  foods  which  our  diabetic  patients 
eat.  Even  the  amount  of  water  taken  can  markedly  influence  the 
rate  of  digestion.  Consequently  in  attempting  to  determine  the 
quantity  of  carbohydrate  derived  from  protein,  this  irregularity  in 
the  excretion  of  nitrogen  must  be  considered.  Tileston  and  Com- 
fort1 found  the  non-protein  nitrogen  normal  in  uncomplicated  cases 
of  diabetes,  but  there  was  retention  in  2  cases  examined  during 
coma.  In  the  series  of  non-protein  nitrogen  determinations  made 
upon  my  cases  it  was  evident  that  these  were  by  no  means  always 
normal  and  might  even  be  considered  high  if  the  preceding  diet 
was  taken  into  account.  There  is  good  ground,  therefore,  for  my 
supposition  expressed  two  years  ago  that  retention  of  nitrogen 
might  easily  complicate  a  dextrose-nitrogen  ratio.  When  one  adds 
to  this  difficulty  that  of  determining  what  share  the  quantity  of 
residual  carbohydrate  in  the  body  bears  to  the  total  sugar  excreted 
the  complexity  of  the  problem  increases.  Case  No.  1213,  with 
apparently  no  tolerance  for  carbohydrate,  excreted  only  10  per  cent, 
of  the  00  grams  levulose  given,  and  her  weight  was  but  31  kilograms. 
Furthermore,  when  one  considers  that  even  under  an  absolutely 
uniform  diet  of  1000  grams  meat  and  1 750  c.c.  fluid  intake  for  fifteen 
days  Naunyn2  found  variations  in  the  excretion  of  sugar  from  12 
grams  to  43  grams,  and  frequently  of  100  per  cent.,  I  feel  very 
modest  about  asserting  that  my  patients  are  producing  any  given 
quantity  of  sugar  for  each  gram  of  nitrogen  which  they  excrete. 
If  under  ideal  conditions  for  fifteen  days  such  variations  exist,  it 
behooves  one  to  accept  with  caution  reported  D  :  N  ratios  for  a 
period  of  a  few  days  or  to  base  arguments,  as  is  sometimes  done, 
upon  the  D  :  N  ratio  of  the  urine  of  every  third  day. 

TABLE  78. — DEXTROSE-NITROGEN  RATIOS  IN  EXCESS  OF  3.65  TO  1. 


Author. 


Murlin  and  Graver3  .  4.2 

Geyelin  and  DuBois4  !   1 . 73 

Christie5    .      .      .      .  |  3.18 

Allen  and  DuBois6     .  2.28 


D: 

V  ratios  upon  successive  days. 

Immediate 
outcome. 

4.0 

!   4.0 

3.5 

3.1 

Recovery. 

3.97 

4.01 

3.87 

2.76 

Recovery. 

2.4 

3.93 

2.51 

3.27 

Recovery. 

3.93 

3.14 

3.10 

3.44 

3.82 

Recovery. 

In  Table  78  I  have  collected  a  series  of  dextrose-nitrogen 
ratios  in  excess  of  that  of  3.05  :  1.  Hitherto  a  patient  who 
showed  a  dextrose-nitrogen  ratio  above  3.05:1  has  frequently  stood 

1  Tileston  and  Comfort :  Arch.  Int.  Med.,  1914,  xiv,  p.  620. 

2  Naunyn:  Loc.  eit.,  p.  183. 

3  Murlin  and  Graver:  Jour.  Biol.  Chem.,  1916,  xxviii,  p.  301. 

4  Geyelin  and  DuBois:  Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  p.  1532. 

5  Christie:  Jour.  Am.  Med.  Assn.,  1917,  Ixviii,  p.  170. 

6  Allen  and  DuBois:  Arch.  Int.  Med.,  1916,  xvii,  Part  II,  p.  1010. 


i:>4     FACTORS   IX    TREATMENT  OF   DIABETES   MELLITl'S 

convicted  of  larceny,  if  not  of  perjury.  The  reputation  of  these 
workers  will  allow  no  such  interpretation.  Xo  one  believes  today 
that,  the  human  1):X  ratio  exceeds  .'>.(>."):  1.  Higher  ratios  are 
illustrations  of  irregularities  in  excretion  of  the  two  substances. 
That  4  cases  should  have  recovered  with  such  ratios  is  confirma- 
tory of  this  conclusion. 

X'ew  light  upon  the  ]):X  ratio  has  recently  been  offered  by 
Janney,1  who  has  worked  out  an  exact  method  for  the  determina- 
tion of  the  formation  of  glucose  in  the  animal  body.  By  feeding 
various  forms  of  animal  protein  to  fasting  phlorhizinized  dogs,  he 
demonstrated  that  f)8  per  cent,  of  these  proteins  went  over  into 
glucose.  By  these  direct  experiments  and  other  proofs  which 
cannot  be  entered  into  here,  he  concludes  that  the  actual  D:X 
ratio  is  o.4  :  1. 

If  one  would  determine  the  dextrose-nitrogen  ratio  accurately 
in  patients,  the  following  requisites  should  be  fulfilled:  (1)  an 
exclusive  fat  protein  diet  or  fasting;  (1))  surroundings  which  make 
errors  in  diet  impossible;  (8)  a  period  of  observation  of  at  least 
seven  days  to  exclude  the  washing  out  of  stored  carbohydrate; 
(4)  a  constant  (not  falling)  I)  :  X  ratio  of  .'!.('>."):  1  for  the  last  three 
of  the  seven  days,  and  (•">)  several  daily  blood-sugar  determinations 
to  furnish  some  proof,  inadequate  though  it  be,  that  the  sugar  in 
the  urine  has  not  come  from  that  left  over  in  the  blood. 

(i.  The  Storage  of  Carbohydrates  in  Diabetes. — It  is  well  known 
that  following  a  period  of  fasting  large  quantities  of  carbohydrate 
can  be  administered  without  immediately  appearing  in  the  urine. 
The  best  illustration  of  this  is  von  Xoorden's  oatmeal  treatment. 
Thus  Case  Xo.  'U4  (see  p.  410)  showed  a  positive  carbohydrate 
balance  of  .li'l)  grains  when  undergoing  an  oatmeal  cure  under  the 
direction  of  Professor  von  Xoorden,  although  he  never  after  this 
cure  became  sugar-free,  despite  a  rigorous  diet,  save  for  occasional 
days.  A  more  spectacular  demonstration  is  the  severe  diabetic  of 
Klemperer-  who  took  100  grams  of  glucose  in  divided  portions  during 
twenty-four  hours  without  its  appearing  in  the  urine.  Almost  as 
impressive  is  that  of  Case  Xo.  7S.~),  a  boy,  aged  seventeen  years, 
who  came  to  me  in  the  twentieth  month  of  the  disease.3  By  con- 
sulting Table  79  il  will  be  seen  that  only  7  grams  of  sugar 
appeared  in  the  urine  following  an  intake  at  one  time  of  SI  grams 
levulose,  although  by  observations  before  and  after  the  tolerance 
was  known  to  be  nearly  ////. 

I  low  large  a  quantity  of  carbohydrate  it  is  possible  for  the  body 
to  store  is  really  unknown,  but  its  importance  is  none  the  less 

1  Janney:      AIM.  Jour.  Med.  S<>.   1917,  .-liii.  p.   14. 

'-'  Kleuiporor:  Therapip  dor  (ienemvart,  I'.Ul.  In.  p.  447. 

;i  For  other  examples  see  p.  3<8. 


TOTAL  METABOLISM  IX  DIABETES  MELLITUS          135 

evident.  Unless  the  amount  of  stored  carbohydrate  is  known  it  is 
unjustifiable  to  say  that  the  carbohydrate  excreted  represents  a 
part  of  that  ingested  during  the  same  twenty-four  hours.  All  data 
with  reference  to  the  I):X  ratio  are  confused  by  our  ignorance 
of  stored  carbohydrate.  The  influence  of  carbohydrate  so  stored 
in  the  body  upon  carbohydrate  assimilation  or  retention,  but  not 
necessarily  utilization,  is  also  great.  Whatever  virtue  the  oatmeal 
cure  possesses,  all  agree  that  it  depends  in  major  part  upon  preceding 
starvation,  which  has  tended  to  exhaust  the  carbohydrate  depots 
of  the  bodv. 


TABLE  79 


Case  Xo.  785.     Mule,  aged  seventeen  years. 


Output. 

Intake. 

Days 

Vol., 

Diac.,     SuKar, 

Nitrogen 

Annn 

onia. 

Carl)., 

Protoil 

,     Fat, 

Alcohol 

Calories. 

c.c. 

Kins.        >;nis. 

K"is. 

gl 

IS. 

Kins. 

Kins. 

gins. 

Kins. 

1-7 

10801 

+            II2 

T.s 

17 

58 

127 

9 

1506 

s 

960 

+            7 

0.5 

0. 

69 

903 

21 

30  ± 

3 

735  ± 

9 

390       ++          •"> 

4.3 

o. 

35 

20 

63 

110 

9 

1385 

10 

1175         +            3 

8.4 

0. 

74 

20± 

03 

1  1  0  ± 

9 

13S5± 

((/)  Storage  of  Carbohydrate  as  Glycogen. — ( 'arbohydrate  is  stored 
in  the  body  in  various  ways,  but  most  of  it  is  supposed  to  be  in  the 
form  of  glycogen,  and  this  is  about  equally  divided  between  the 
liver  and  muscles.  An  old  estimate  of  Bunge  that  the  body  con- 
tained 400  grams  carbohydrate,  is  roughly  approximated  by  experi- 
ments upon  fasting  men  and  professional  athletes  doing  severe 
work  without  food.  This  figure  may  be  taken  as  a  fair  average, 
but  there  are  enormous  variations.  This  statement  is  based  upon 
glycogen  which  has  been  shown  to  be  burned  in  calorimetric  experi- 
ments; it  does  not  exclude  the  possibility  of  some  glycogen  still 
remaining  in  the  body.  Experiments  on  fasting  men  show  that 
they  may  burn  from  93  to  232  grams  of  glycogen  in  the  first  three 
days  of  a  fast.4 

In  diabetic  patients  the  quantity  of  glycogen  is  universally 
considered  to  be  far  below  this  amount,  but  Frerichs5  found,  upon 
puncturing  the  liver  of  two  diabetics,  a  small  amount  of  glycogen 
in  one  and  a  considerable  amount  in  the  other,  and  Kiilx  found 


4  Benedict:    The  Influence  of   It 
1907,  Pub.  77,  p.  404;  Benedict: 
Washington,   1915,  Pub.  203,  p.  2 

5  Frerichs:   ('it.    Xehring  and   Si 
Pfiugcr's  Archiv,  1870,  xiii,  p.  207. 


inition  on  Metabolism,  Carnegie  lust,  of  Wash., 

V  Study  of  Prolonged   Fasting,  Carnegie  Inst.  of 

51. 

hmoll:    Ztschr.   f.   klin.    Men1.,    Is97,    xxxi,   p.  59; 


136     FACTORS  IX   TREATMENT  OF  DIABETES  MELLITUX 

10  to  12  grains  glycogen  in  the  liver  of  a  diabetic  who  had  been  foi 
a  long  time  on  a  diabetic  diet.  Examinations  of  the  tissue  removed 
from  the  livers  of  living  diabetic  patients  also  show  appreciable 
quantities  of  glycogen,  and  it  is  the  experience  of  pathologists  that 
the  organs  of  diabetic  patients  contain  more  than  traces  of  glycogen. 
It  is  most  unfortunate  that  no  data  exist  which  enable  us  to  deter- 
mine what  this  minimum  is.  It  is  quite  conceivable  that  although 
it  might  be  extremely  small  at  any  one  moment,  a  small  quantity 
might  be  continuously  formed  and  destroyed,  and  the  sum  of  these 
small  quantities  reach  a  substantial  amount  in  twenty-four  hours. 

The  recent  work  of  Kelly1  throws  new  light  upon  the  problem, 
lie  points  out  the  striking  contrast  between  the  constant  presence 
of  glycogen  in  the  liver  of  human  diabetes  and  the  very  small 
quantity  which  is  found  in  the  severe  diabetes  of  depancreatized 
dogs,  yet  even  in  the  latter  the  power  of  the  liver  to  form  or  deposit 
glycogen  is  shown  when  levulose  is  administered.  If  a  milder  form 
of  diabetes  is  produced  in  the  dog  more  glycogen  remains  in  tin- 
body  and  there  is  a  closer  resemblance  to  human  diabetes.  Whereas 
with  total  removal  of  the  pancreas  there  was  only  0. 00")  per  cent, 
of  glycogen  in  the  liver;  with  partial  removal  there  was  0.3  per  cent, 
of  glycogen,  even  though  S  to  10  per  cent,  of  sugar  remained  in  the 
urine.  By  microscopic  examination  so  considerable  a  quantity  as 
this  appeared  small. 

Woodyatt2  found  that  the  muscle  of  a  case  of  severe  human 
diabetes  formed  even  less  lactic  acid  than  that  of  fully  phlorhizinized 
dogs.  This  suggests  an  impaired  power  to  dissociate  glucose  on 
the  part  of  the  diabetic  muscle,  since  such  muscles  are  bathed  with 
an  abnormally  high  quantity  of  sugar  which  if  available  should 
yield  more  lactic  acid  than  is  found  in  the  muscle  of  phlorhi/in 
diabetes.  Kleiner3  finds  in  agreement  with  other  observers  that 
large  amounts  of  sugar  injected  intravenously  into  a  normal  dog 
disappear  from  the  circulating  blood  in  about  ninety  minutes  after 
the  end  of  the  injection  and  only  about  00  per  cent,  are  excreted 
in  the  urine.  The  same  quantity  will  leave  the  blood  in  nephrec- 
tomi/ed  animals.  This  occurs  even  after  intravenous  injection 
into  dead  animals.  An  increase  in  carbohydrate  of  the  muscle 
tissue  was  found  and  there  was  also  evidence  of  the  formation  of 
polysaccharides  in  the  muscle  tissue. 

(h)  Storage  of  Carbohydrate  as  Blood  Sugar. — Sugar  is  also  stored 
in  the  body  in  the  form  of  blood  sugar.  The  normal  quantity  of 
sugar  in  the  blood  of  healthy  individuals  varies  between  0.07  and 
0.1 1  per  cent.,  and  for  convenience  in  calculation  may  be  considered 

1  H.'lly:   /tschr.  f.  exp.  Path.  a.  Therap.,  1914,  xv,  p.  464. 
-  Woodyatt:    Jour.  Mini.  Chcin.,  I'll:*!,  xiv,  p.  411. 
3  Kleiner:    Jour.  Kxp.  Med.,  I'JIO,  xxiii,  p.  "»()7. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          137 

0.1  per  cent.  This  rises  quickly  after  a  meal  rich  in  carbohydrates, 
but  soon  falls  to  its  former  level.  Of  191  observations  upon  72 
of  our  diabetic  patients,  the  percentage  of  blood  sugar  varied  from 
0.45  to  0.07  per  cent.1  But  the  blood  of  these  diabetic  patients 
does  not  behave  like  that  of  normal  individuals  following  the 
ingestion  of  food.  It  is  true  that  the  percentage  of  sugar  rapidly 
increases  following  a  carbohydrate  meal,  but  it  does  not  as  rapidly 
fall,  and  in  my  own  experience  most  diabetic  patients,  even  after 
prolonged  fasting,  show  values  for  blood  sugar  which  are  far  above 
normal.  Certain  types  of  diabetic  patients — namely,  those  with 
disease  of  the  kidneys — are  expecially  prone  to  maintain  high 
percentages  of  sugar  in  the  blood  for  many  days  after  their  urines 
have  become  sugar-free.  It  is  impracticable  to  consider  that  the 
percentage  of  blood  sugar  is  maintained  independently  of  the  other 
tissues  in  the  body  because:  (1)  the  percentage  is  so  unstable; 
(2)  there  is  no  constant  relation  between  the  sugar  in  the  blood 
serum  and  the  sugar  in  the  total  blood ;  and  (3)  because  the  capacity 
of  the  blood  for  storage  of  sugar  is  so  slight.  Confirmation  of  the 
above  statements  has  been  afforded  by  the  ingenious  experiments  of 
Woodyatt  and  his  co-workers  to  be  later  described  (see  p.  255). 
If  we  assume  an  individual  of  70  kilograms  body  weight  and  con- 
sider that  7  per  cent,  of  his  weight  is  made  up  of  blood,  we  have 
4.9  kilos  of  blood  of  which  the  sugar  content  is  0.1  per  cent.  This 
would  amount  to  4.9  grams,  even  taking  the  highest  for  the  normal 
individual,  and  should  we  take  the  highest  figures  we  have  encoun- 
tered even  after  the  administration  of  food  with  our  recent  diabetic 
patients,  namely,  0.45  per  cent.,  the  total  quantity  of  sugar  stored 
in  the  blood  would  not  be  far  from  22  grams,  a  trifle  more  than 
two-thirds  of  an  ounce.  Falta2  has  called  attention  to  the  slow 
return  of  the  blood  sugar  of  diabetic  patients  after  a  carbohydrate 
meal  to  its  former  sugar  level.  Kleiner  and  Meltzer3  have  also 
beautifully  shown  this  same  difference  to  exist  between  normal  and 
depancreatized  dogs.  Whereas  the  sugar  in  the  blood  of  normal 
dogs  increases  fourfold,  namely,  from  0.20  per  cent,  to  0.79  per  cent., 
following  the  injection  of  4  grams  of  dextrose  per  kilogram  body 
weight,  and  of  depancreatized  dogs  threefold,  from  0.38  per  cent., 
before  to  1.19  per  cent,  after  the  injection,  the  blood  sugar  of  the 
former  returned  nearly  to  normal  at  the  end  of  an  hour  and  a  half, 
while  diabetic  dogs  then  showed  O.SG  per  cent.  It  is  significant 
that  in  these  experiments  the  quantities  of  sugar  excreted  in  the 
urine  were  practically  the  same.  Interesting  as  these  figures  are 
from  this  point  of  view,  they  are  still  more  interesting  from  another 

1  In  a  later  case,  Xo.  1015,  it  amounted  to  1.37  per  cent.     See  p.  88. 

2  Falta:    Med.  Klinik,  1914,  x,  p.  9. 

3  Kleiner  and  Meltzer:  Proc.  Soc.  for  Exp.  Biol.  and  Med.,  1914,  xii,  p.  58. 


i\  TUEATMKXT  or  DIAHKTKX  MELI.ITCS 

point  of  view.  It  is  impossible  to  account  for  all  the  sugar  ingested 
by  adding  together  the  sugar  found  in  the  blood  and  that  in  the 
urine,  \\here  did  the  sugar  go?  One  may  say  it,  was  burned,  and 
this  possibility,  though  not  probability,  must  be  admitted  in  the 
normal  animal,  but  no  one  would  contend  this  to  be  wholly  the  case 
in  the  depancreati/ed  animals.  Here  again  \\oodyatts  work 
oilers  new  methods  which  we  all  hope  will  throw  light  upon  this 
problem. 

At  the  Nutrition  Laboratory  we  have  been  able  to  carry  those 
experiments  to  their  logical  conclusion,  for  we  have  had  the  oppor- 
tunity to  determine  the  respiratory  quotient  following  the  adminis- 
tration of  levulose  to  severe  diabetic's.  In  Table  Si  will  be  found 
a  report  of  some  of  these  experiments  upon  the  effect  of  levulose 
when  administered  to  severe  diabetic  patients  m  amounts  of  2..">1 
grams,  2.42  grams  and  1 .'.).")  grams  per  kilogram  body  weight.  In  the 
first  and  third  cases  there  was  no  increase  in  the  respiratory  quotient. 
A  considerable  portion  of  the  levulose  was  probably  excreted  in  the 
first  case,  but  in  the  others  little  or  none.  The  explanation  of  this 
difference  in  behavior  in  the  storage  of  levulose  among  the  three 
patients  appears  to  be  that  the  first  cast1  had  not  fasted  beforehand 
and  that  the  third  had  been  on  a  lo\v  carbohydrate  diet  for  a  long- 
time; this  is  confirmed  by  the  second  case,  which  also  excreted 
little  of  the  levulose,  for  it  was  administered  following  a  period  of 
strict,  dieting.  At  the  present  time  Benedict  and  I  are  compiling 
our  experiments  with  levulose.  These:  are  extensive,  and  as  yet  our 
conclusions  have  not  been  drawn.  They  will  be  reported  shortly 
in  a  monograph  to  be  issued  by  the  Carnegie  Institution  of  Wash- 
ington. 

(<")  Influence  of  Rate  at  which  Carbohydrate  is  Administered.-  it 
should  also  be  recorded  that  in  all  these  .'!  cases  the  levulose  was 
given  at  one  time  and  not  in  divided  doses  throughout  the  twenty- 
four  hours,  as  in  Klemperer's  test,  and  yet  the  carbohydrate  was 
stored  by  the  body  in  two  approximately  as  well.  This  gives  added 
emphasis  to  the  possibility  of  the  presence  of  an  empty  storehouse 
for  carbohydrate  in  the  body.  I  also  have  evidence  that  the  gradual 
administration  of  carbohydrate  is  of  little  value,  provided  the  body 
is  not  prepared  to  retain  it.  Following  etherization,  a  patient. 
Case  Xo.  SOS,  while  fasting  for  the  first  twenty-four  hours,  was 
sugar-free,  but  on  the  next  day,  though  only  2  grains  carbohydrate 
per  hour  were  administered,  he  excreted  practically  all  of  it,  though 
formerly  his  tolerance  amounted  to  .">()  grams  carbohydrate.  Com- 
pare the  behavior  of  Case  Xo.  C>(.>7  after  two  operations,  when 
different  anesthetics  were  employed.  (See  p.  112.)  It  is  not 
strange  that  carbohydrate  is  probably  better  tolerated  at  breakfast 
than  at  anv  other  time  in  the  dav. 


TOTAL   METABOLISM   IX   DIABETES   MELLITUX          139 

(d)  Other    Possible    Storehouses    for    Carbohydrate. — The    small 
amount  of  glycogen  in  the  body  and  the  still  smaller  quantity  of 
blood  sugar  represent  an  amount  of  carbohydrate  far  too  lo\v  to 
account  for  the  phenomena  above  described  in  diabetes.     Other 
sources  for  storage  of  sugar  in  the  body  must  be  sought,  and  this 
has  been  emphasized  by  Ivar  Bang.1    If  we  should  assume  that  the 
percentage  of  sugar  was  the  same  for  all  the  fluids  in  the  body  asin 
the  blood,  certain  amounts  of  sugar  might  be  stored  in  this  manner, 
^hile  such  an  assumption  is  not  wholly  justifiable,  it  has  some 
basis,  for  we  know  that  sugar  exists  in  the  spinal  fluid  of  diabetics 
as  well  as  in  other  fluids.    In  normal  individuals  Dr.  Jacobson  tells 
me  that  he  has  not  found  it  so  closely  to  follow  the  blood  but  the 
opposite  was  true  in  his  cases  of  diabetes  mellitus.     Hopkins2  has 
observed  in  diabetic  patients  that  the  reducing  substances  in  the 
spinal  fluid  were  but  slightly  less  than  the  blood  sugar  of  the  same 
individuals.    These  varied  from  a  minimum  of  0.074  to  a  maximum 
of  0.623  for  the  spinal  fluid  and  the  corresponding  values  for  the 
blood  were  0.077  and  0.600.    Notable  percentages  of  sugar,  not  very 
different  from  those  in  the  blood,  have  been  found  in  pleuritic  and 
ascitic  fluids,  and  Husband3  found  even  0.7  per  cent,  in  theamniotic 
fluid.     Yet   granted  that  the    assumption  of  uniform  distribution 
of  sugar  in  the  fluids  of  the  body  is  correct,  we  cannot  increase  our 
storage  capacity  very  much  in  this  way.     For  example,  assuming 
the  total  quantity  of  fluid  in  the  body  as  00  per  cent,  of  the  body 
weight  of  70  kilograms,  we  have  42  kilograms  of  body  fluid,  from 
which  we  must  deduct  4.0  kilograms  already  reckoned  as  blood. 
This  leaves  us  a  remainder  of  37.1  kilograms  of  fluid  in  the  body, 
and  using  the  highest  figure  (0.45  per  cent.)  for  blood  sugar  which 
we  have  personally  encountered,  the  quantity  of  sugar  in  this  mass 
of  fluid  would  be  only  107  grams.    This  is  not  enough  relatively  to 
explain  Kleiner  and  Meltzer's  experiment  and  far  less  those  of 
Woodyatt. 

(e)  Body  Protein  and  Carbohydrate  Storage. — Another  source  for 
the  formation,  though  perhaps  not  for  the  storage  of  carbohydrate 
in  the  body,  has  long  been  recognized  in  protein.    The  close  con- 
nection which  is  maintained  between  protein  and  carbohydrate  in 
diabetes  would  make  a  clinician  with  modest  chemical  knowledge 
seek  for  some  combination  of  carbohydrate  in  the  protein  molecule — 
some  arrangement  by  which  a  portion  of  the  sugar  molecule  could 
be  stored  in  protein  or  attached  to  protein  and  given  up  as  occasion 
arises,  ju>t  as  water  is  squeezed  out  of  a  sponge.    Good  chemists 
(and  I  have  asked  many)  assure  me  that  it  is  impractical  to  consider 


140     FACTORS  IX   TREATMEXT  OF  DIABETES  MELLITUS 

such  a  combination,  and  that  one  must  consider  that  even  with 
glueoproteids  sugar  can  only  be  extracted  from  the  protein  molecule 

when  the  molecule  itself  is  disintegrated.  If  disintegration  does 
take  place  then  (50  grams  of  carbohydrate  may  be  derived  from 
each  100  grams  protein.  The  large  quantity  of  movable  protein 
and  fat  in  the  body  suggests  a  large  carbohydrate  reservoir  also. 
Few  realize  how  large  this  quantity  of  movable  protein  is.  It  has 
been  shown  by  Albert  Mueller,  of  Vienna,1  that  by  overfeeding 
it  is  possible  to  add  210  grams  of  nitrogen  to  the  body,  and  this 
would  be  the  equivalent  of  1200  grams  of  body  protein,  in  turn 
the  equivalent  of  (5.3  kilograms  of  muscle  tissue.  Conversely, 
it  has  been  shown  by  Professor  Benedict2  that  a  similar  quantity 
can  be  removed.  This  movable  protein  amounts  to  about  one- 
third  of  the  total  body  protein.  The  readiness  with  which  fat 
can  be  increased  and  decreased  in  the  body  is  so  universally  recog- 
nized as  to  be  overlooked.  If  we  conceive  that  it  is  possible  for  a 
severe  case  of  diabetes  to  form  (50  grains  of  carbohydrate  from 
100  grams  of  protein,  then  from  the  movable  protein  of  the  normal 
individual,  which  has  just  been  shown  to  be  12(50  grams,  it  would 
be  possible  to  form  7.">(5  grams  of  carbohydrate. 

7.  Utilization  of  Carbohydrate  in  Diabetes.  —  The  demonstration 
of  the  utilization  of  carbohydrate  in  diabetes  is  as  scientifically 
difficult  as  it  is  apparently  simple.  Nothing  would  appear  easier 
than  to  say  that  when  a  patient  ingests  50  grams  of  carbohydrate 
in  the  diet  and  excretes  2o  grams  of  sugar  in  the  urine  the  balance 
of  2")  grams  was  utilized.  I  low  complicated  the  situation  actually 
is  can  be  seen  by: 

(d)  A  study  of  what  constitutes  the  carbohydrate  balance. 

(b)  The  influence  of  the  changing  weight  of  the  patient. 

(c)  The  capacity  of  the  body  for  storage  of  carbohydrate. 

(d)  The  difficulties  attendant  upon  the  use  of  the  respiratory 
metabolism  as  an  index  of  combustion  of  carbohydrate. 

(e)  Finally,  the  effect  of  exercise  upon  the  carbohydrate  utiliza- 
tion. 

Before  entering  upon  a  discussion  of  each  of  these  topics  in  detail 
I  quote  the  closing  sentence  of  my  Harvey  Lecture  ::i  "  In  conclusion, 
it  is  gratifying  to  be  able  to  record  that  the  recent  experimental 
evidence  confirms  the  old  clinical  view  that  the  severe  diabetic 
still  retains  power  to  utilize  a  portion  of  the  carbohydrate  of  his 
diet,  small  though  it  may  be,  and  that  herein  lies  renewed  hope  for 
the  success  of  treatment." 


1  Mueller:  ZcntralU.  f.  d.  (lc>annn!.>    I'h 
p.  017. 

-T;irMO<ric  Till).  Xo.  20U,  p.  251. 

3  Joslin:    Harvey  Lectures,  J.  Ji.  Lippincott  Company,  1914-1915. 


TOTAL  METABOLISM  IN  DIABETES  MELLITUS          141 

(a)  Carbohydrate   Balance. — Grossly,  the   carbohydrate   balance 
is  of  much  value  in  estimating  the  utilization  of  carbohydrate, 
provided  that  no  radical  changes  are  made  in  the  patient's  diet 
from  day  to  day.    By  the  carbohydrate  balance  is  understood  the 
difference  between  the  quantity  of  carbohydrate  ingested  in  the 
diet  in  the  form  of  sugar  and  starch  and  that  excreted  in  the  urine 
as  sugar.    An  individual  who  ingests  50  grams  of  carbohydrate  and 
excretes  25  grains  of  dextrose  in  the  urine  is  said  to  have  a  positive 
balance  of  25  grams  (+25),  but  if  the  carbohydrate  in  the  diet  is 
25  grams  and  the  dextrose  in  the  urine  50  grams  he  is  said  to  have 
a  negative  carbohydrate  balance  of  25  grams  ( —  25).   Unfortunately 
these  figures  contain  many  errors  of  inaccuracy.    In  the  first  place 
they  presuppose  that  the  carbohydrate  in  the  diet  is  accurately 
known,  and  from  what  is  said  elsewhere  this  is  seldom  the  case, 
even   under  the  most  favorable  conditions.     Second,   the   carbo- 
hydrate in  the  diet  is  estimated  as  dextrose,  whereas  in  reality  only 
a  portion  is  dextrose,  the  remainder  being  starch,  and  it  should 
be  pointed  out  that  100  grams  of  starch  converted  into  dextrose 
yield    105    grams    dextrose.      Third,    the    carbohydrate    balance 
depends  upon  the  assumption  that  all  the  unutilized  carbohydrate 
formed  from  food  eaten  during  the  twenty-four  hours  is  excreted 
during  the  same  twenty-four  hours  in  the  urine.     It  is  probable 
that  this  assumption  is  frequently  correct,  but  it  certainly  is  not 
invariably  so,  and  it  is  often  difficult  to  determine  just  when  the 
excretion  of  carbohydrate  is  delayed.    Enough  has  been  said  about 
the  storage  of  carbohydrate  to  show  that  frequently  quantities  of 
carbohydrate  can  be  retained  in  the  body  for  many  hours  without 
assimilation,  and  ultimately  be  excreted  in  the  urine.    The  literature 
upon  oatmeal  is  rich  in  such  experiments,  von  Noorden  in  particular 
calling  attention  to  3  cases  in  which  very  little  sugar  was  actually 
excreted  during  the  oatmeal  cure,  but  in  one  of  which  during  the 
following  three  days,   90,    100,   and  22  grams  respectively  were 
excreted.    Undoubtedly  a  better  appreciation  of  the  carbohydrate 
balance  would  be  obtained  by  comparing  the  carbohydrate  ingested 
in  the  course  of  longer  periods,  for  example,  one  or  two  weeks, 
with  that  excreted  during  the  same  interval. 

(b)  Weight. — If  the  weight  of  a  diabetic  patient  remains  constant 
and  a  definite  quantity  of  carbohydrate  is  added  to  the  diet  and  the 
weight  increases,  at  first  sight  one  would  appear  justified  in  claiming 
that  the  carbohydrate  was  utilized.  I  low  unsound  such  a  conclu- 
sion would  be  has  been  pointed  out  in  the  preceding  section  under 
observations  upon  weight.  In  a  mild  case  of  diabetes  such  a 
permanent  and  constant  gain  in  weight  under  such  conditions  might 
be  considered  proof  of  carbohydrate  utilization,  but  in  the  severe 
cases  of  diabetes  where  obviously  the  total  grams  of  carbohydrate 


142     FACTO HH   7.V    TKKATMKM'  OF   DIABETES   MELL1TU8 

assimilated  would  not  be  at  the  most  above  10  to  20  grains,  one 
could  not  think  of  determining  the  utilization  of  the  carbohydrate 
in  this  way. 

(c)  Capacity  for  Storage.      In  any  consideration  of  the  carbohydrate 
balance  the  possibility  of  storage  of  carbohydrate*  as  opposed  to  the 
utilization  of  carbohydrate  must  be  borne  in  mind.     It  is  sufficient 
here  to  simply  refer  to  what  has  been  previously  said  in  this  section, 
on  page   K>4,  upon  this  point. 

(d)  Respiratory  Quotient,     (treat  hopes  were  entertained  that  the 
changes    in    the    respiratory   quotient   following   the    ingestion    of 
carbohydrate    would    definitely    show    whether   any   was    utilized. 
It  i^  true  that  the  many  experiments  at  the  Nutrition  Laboratory 
tend  to  point  to  a  utilization  of  a  small  quantity  of  carbohydrate, 
even   in  the  severest  forms  of  diabetes.      When  it  is  considered, 
however,  that  even  the  utilization  of  24  grams  of  carbohydrate  in 
twenty-four  hours  at  the  rate  of  1  gram  an  hour  could  not  be  readily 
shown  by  methods  of  studying  the  respiratory  metabolism  now  in 
use,  it  is  evident  that  proof  of  utilization  of  carbohydrate  needs 
further  study.     1  nquestionably,  the  respiratory  metabolism  is  the 
most  accurate  means  of  proving  carbohydrate  utilization,  but  it 
is  a  method  which  at  present  cannot  be  expected  to  show  whether 
small  quantities  of  carbohydrate  are  utilized  or  not.    Tables  (SO  S3 
ilhi>trate  the  effect  of  the  ingestion  of  various  carbohydrates—  levu- 
losc,  oatmeal,  potato-   upon  the  respiratory  metabolism  as  shown 
by  changes  in  the  respiratory  quotient.     Whereas  comparatively 
slight  changes  in  the  respiratory  quotient  following  the  administra- 
tion of  these  carbohydrates  to  severe  diabetics  were  observed,  still 
the  general  tendency  points  to  a  slight  utilization  of  the  carbo- 
hydrate.    It  is  noteworthy,  however,  that  Cases  No.  MM-  and  441, 
with  positive  carbohydrate  balances  of  100  grams  or  more  for  the 
day  of  the  experiment  gave  in  the  former  instance  a  respiratory 
quotient  of  0.71  before  and  immediately  following  the  administra- 
tion of   oatmeal,   and    in   the   latter  0.70   before  and   0.71    directly 
afterward. 

In  future  experiments  upon  the  utilization  of  carbohydrate,  it 
must  be  borne  in  mind  that  the  rapidity  with  which  diiferent  foods 
enter  into  the  metabolism  varies.  Thus  Higginshas  shown  upon 
normal  individuals  that  sucrose,  lactose  and  levulose  begin  to  be 
burned  quite  as  soon  as  alcohol  if  not  sooner;  glucose  and  maltose 
are  not  utilized  as  food  as  soon  as  the  other  sugars  or  alcohol, 
approximately  twenty  to  thirty  minutes  elapsing  before  their 
combustion  plays  an  important  part  in  the  metabolism.1 


TOTAL   METABOLISM   IN  DIABETES   MELLITl'S  143 

TABLE  80. — -EFFECT  OF  LEVTILOSE  AND  OATMEAL  ox  A  SEVERE  DIABETIC. 
Case  '.V.V2.      Female.     A^c-d  thirty-seven  years.     Weight  40  kilos. 


Date. 
March  31,  1011: 

10.50  .  .  .  Fasting 
11.23  .  .  .  Fasting 

12.10 172  271  0.03  40 

12.44    ...  1S4  201  0.70  44 

1.30 ISO  210  0.73  42 

2.05 172  235  0.73  40 

2.2S    ...  ..  171  250  O.OS  42 

2.53     ...  ..  166  240  0.00  40 

April  2,  1011: 

S.I  7  .  .  .  Fasting 
S.45  .  .  .  Fasting 
0.14  .  .  .  Fasting 

Oat  me 

10.13     ...  ..  103  234  0.70  30 

10.30    .       .  ..  107  22S  0.73  30 

11. OS 177  23S  0.75  40 

12.12 170  230  0.74  39 

1.2S    .      .      .  ,.  154  200  0.75  35 

2.37 103  200  0.7S  36 

TABLE  SI. — EFFECT  OF  LEVULOSE  UPON  THE  RESPIRATORY  QUOTIENT 
OF  DIABETIC  PATIENTS. 

Carbo- 
hydrates. SiiKar  in  Respiratory 
Duration,     Month  of     preceding  urine  quotient. 

months,  observation.        day,  Levulose,       24  hours,  Before            After 

Case.                      Dead.                                   Kins.  K»is.               Kins.  levulose.     levulose. 

332    .  2S  23  100  = 


552    .       .       .      32  IS  30  100  3 

7S5    .  .      23  20  20  SI1  7  No  increase. 

TABLE  82. — -EFFECT  OF  POTATO  o.v  RESPIRATORY  QUOTIENT  IN"  SEVERE 

DIABETES. 

Carbohydrate  intake.         Suwir  in  Respiratory 

Case.  Duration,    Months,        I'rceediiiK        Test  day,        urine  2 1  quotient. 

\Io.  months,    observed.-    day.  KIIIS.  K'ns.         hours,  gins.       Before.         After. 

03  - 
705   ...       7  3  15  22  20  0.74          0.73 

85 
SOO    ,  6  3  10  03  O.OS          0.71 


'  Si  gins,  lovulose  and  later  0  gins.  carl),  as  vegetables — 00  gins,  total. 

2  4S  gin-,  carl),  as  potato;  10  gins.  carh.  as  oatmeal;  5  gins.  carl),  as  cream,   total 
63  gins.;  later  in  day,  22  gins.  carh.  as  potato  and  vegetables;  also  one  egg  and  30 
gins,  butter. 

3  60  gms.  carh.  as  potato;  later  in  day,  one  egg.  butter,  (i  gins.  carl),  as  vegetables. 


144     FACTORS  IN   TREATMENT  OF  DIABETES  MELLITUS 

TABLE  83. — EFFECT  OF  POTATO  ox  THE  RESPIRATORY  QUOTIENT  OF  A 
SEVERE  CASE  OF  DIABETES. 

Case  SOI).     Male.     Weight,  02  kilos. 


C(  >2  per 

O2  per                                             ( 

'alories  per            Blood 

min., 

min.,                Respiratory 

kilo,  per               .sujjnr. 

Date.            Condition. 

c.c. 

c.c.                    quotient. 

24  hours.             per  cent 

Dec.  22,  1914: 

9.25  } 

f  150 

223              0.70' 

'241 

9.54   •  Fasting     . 

\   150 

224               0.07  i-O.OS 

24  j-  24 

10.22  j 

[loo 

228              0  .  OS  J 

10  15 

0   14 

Potato  -  ti()  tz 

us.  curb. 

10  55 

0   18 

1  1  59           .... 

181 

257              0.71  1 

28 

12.22    

10S 

252              0.07      0.09 

27     27 

172 

250              ().0(.) 

~>- 

3.00           .... 

170 

233              0  .  73  ' 

20  ' 

3.20    

157 

227               0.70      0.72 

25  \  25 

3  54 

100 

231              0.72 

25  J 

4.45    . 

0.19 

TABLE  84. — EFFECT  OF  OATMEAL  ox  THE  RESPIRATORY  QUOTIENT  OF 
SEVERE  DIABETIC. 

Case  773.     Female.     Weight,  40  kilos. 


Date.         Condition 
Oct.  10,  1914: 

,x.OO          Fast  iny; 


11.00  .       .       .       . 
Oct.  13: 

MM)          Fasting 
11.00  .       .       .       . 
Oct.  19: 
9.00 


.       .      146 

( (at  meal  o  42  ^ms.  carl). 
178 


C0?  per           <>2  per  Calories  Hl< 

min.,               niin.,  Respiratory       per  kilo  suj. 

c.c.                   c.c.  quotient.  per  24  hrs.  per 

212  0.09                   30 

249  0.72                43 

138                189  0.73                33  0. 


101 1 

ar. 
cent. 


Fasting      .      .      .     135  195 

Oatmeal  o  SO  urns.  carl). 

12.00 107  237 

Oct.  20:         After  breakfast 

Diet  contained  15  gins.  carh.  October  9  and  October  IS. 


34 

40 


(c)  Effect  of  Exercise. — The  effect  of  exercise  upon  the  utilization 
of  carbohydrate  has  excited  interest  for  many  years  and  has  recently 
been  advocated  by  Allen.  Yon  Noorden,  referring  to  this  subject, 
writes:  "\\ide  individual  differences  exist  with  regard  to  this 
matter.  It  is  found  that  some  patients  can  tolerate  much  more 
carbohydrate  when  taking  plenty  of  exercise;  with  others  this  is 
not  the  case,  muscular  work  doing  them  more  harm  than  good."1 
At  the  Nutrition  Laboratory  a  small  series  of  experiments  were 
conducted  by  Benedict  and  myself  and  published  in  !!)!(). -  The 
evidence  collected  was  not  enough  to  warrant  general  conclusions, 


'Von  Xoonlen:     Diabetes  Mellitus,  10.  15.  Treat  Company,   1905,  p.  177. 

2  Benedict  and  Joslin;  Metabolism  in  Diabetes  Mellitus,  Carnegie.  Pub.  130,  p.  217. 


TOTAL  METABOLISM  IN  DIABETES  MELL1TUS 


145 


but  insofar  as  it  went,  it  tended  to  show  that  during  exercise  there 
was  a  slightly  increased  combustion  of  carbohydrate,  as  shown 
by  a  rise  in  the  respiratory  quotient  and  also  a  rise  in  the  total 
metabolism. 

TABLE  So. — -EFFECT  OF  OATMEAL  ox  THE  RESPIRATORY  QUOTIENT  OF 
SEVERE  DIABETICS.     For  text,  see  page  142. 


Duration. 

Date. 

Carbohydrates 
ingested. 

Respiratory 
quotient. 

Sugar 
in  urine, 
gnis. 

Carbo- 
hydrate 
intake 
for 
entire 
2-1°, 
gms. 

Carbo- 
hydrate 
balance 
for 
entire 
24°, 
gins. 

Case 
Xo.    Onset 
to 
coma, 
mos. 

Month 
of 
test. 

Day 
preced- 
ing, 
gms 

Before 
test, 
gnis. 

Fast- 
ing. 

After 
oat- 
meal. 

194       34 

31 

Sept.  22 

15 

0.74 

42 

15 

-27 

23 

15 

100  + 

0.71 

0.71 

50 

165 

+  115 

24 

165 

0.72' 

19 

15 

-4 

246       15 

11        Aug.     9 

50 

40 

0.71 

0  .  67 

124 

9                   9 

13 

Oct.    29 

65 

60 

0.68 

0.70 

100 

125           +25 

30 

125 

0.71' 

93 

65           -28 

25-31 

71 

0  .  69 

102 

72           -30 

281 

19 

17 

Dec.      1 

15 

0.75 

69 

135           +60 

2 

135 

29 

0  .  76' 

58 

45 

-13 

3 

45 

0 

0.76 

38 

30 

-8 

332 

28 

•  13 

May   19 

100 

25  ± 

0.73 

15 

in  3  hrs. 

26 

95 

0.73 

3 

in  3  hrs. 

24        April    2 

? 

52 

0.74 

0.74 

97 

26        June     2 

? 

48 

0.71 

0  .  69 

36 

330     132 

127        May   18 

20 

0.73 

26 

45           +19 

21 

45 

25 

0  .  75 

31 

45           +14 

441 

11 

9        Sept.  29 

15 

75 

0  .  70 

0.71 

65 

165         +100 

Oct.      9 

15 

73 

0  .  69 

•) 

79 

561 

33 

23        Feb.      7 

60 

0  .  75 

31 

60           +30 

8 

60 

116" 

0.71 

0.74 

128 

185           +57 

9 

185 

200 

0.72' 

0.72'- 

209 

205             -4 

10 

200 

0  .  76- 

102 

60           -42 

591 

50 

44        April  10 

? 

0.74 

63 

30           -33 

11 

30 

0  .  73 

37 

15           -22 

12 

15 

80 

0  .  70 

0.70 

85 

165           +SO 

13 

165 

80 

0.731 

0  .  691 

77 

165           +88 

15 

40 

0.69 

29 

9 

773 

20 

18        Oct.      8 

115 

70 

0.70 

176 

165           -10 

10 

15 

47 

0  .  69 

0.72 

95 

130           +35 

13 

50 

0  .  73 

84 

50           -34 

19 

15 

80 

0.70 

0.70 

97 

115           +18 

74G 

223 

18                     7 

65 

28 

0  .  73 

93 

65           -28 

9 

15 

50 

0  .  73 

0.71 

87 

163           +76 

10 

165 

0.721 

35 

25           -10 

15 

165 

80 

0.74- 

96 

165           +69 

7S6 

17' 

14        Nov.  12 

15 

60 

0  .  69 

0  .  73 

0 

62           +02 

10 


1  Respiratory  quotient  taken  following  an  oatmeal  day 

2  Respiratory  quotient  taken  subsequent  to  two  oat  me 


140     FACTOh'S  IX    TREAT. MEXT  OF   DIABETES   MELLITl'S 

Nehring  and  Schmoll1  concluded  that  muscular  activity  in  dia- 
betics was  also  at  the  expense  of  glycogen  from  the  fact  that  it  was 
possible  in  many  instances  to  reduce  the  sugar  excretion  by  con- 
trolling the  muscular  activity.  This  is  also  fully  in  accord  with  the 
experiments  made  by  Mohr2  in  which  he  found  with  a  diabetic 
dot;  that  there  was  a  noticeable  increase  in  the  respiratory  quotient 
during  walking,  and  therefore  he  concluded  that  diabetics  can  burn 
but  little  glycogen  until  there  is  the  most  urgent  need  for  it.  No 
other  respiratory  experiments  upon  the  etl'ect  of  exercise;  have  been 
made  by  Benedict  and  me,  but  the  following  clinical  observations 
are  of  interest:  ( "ase  No.  1 1 2,  a  doctor,  and  a  good  observer,  noticed 
that  the  quantity  of  sugar  in  the  urine  always  decreased  while  on 
hard  camping  trips  in  Maine,  although  the  diet  contained  the  same, 
or  probably  more,  carbohydrate  than  when  he  was  at  home.  Case 
No.  22,  a  Harvard  professor,  said  to  me  in  1901  that  "mental  work 
makes  sugar,  manual  work  burns  it  up."  Case  No.  511  shows 
sugar  Avhen  hard  at  work  in  the  city,  but  when  quite  as  occupied 
with  mental  work  in  the  country,  but  with  more  exercise  and  a 
similar  diet,  shows  no  sugar.  Since  my  attention  has  been  directed 
to  this  question  by  Allen's  experimental  work,  I  recall  instances  of 
diabetics  who  were  able  to  carry  on  severe  muscular  labor,  although 
the  diabetes  was  of  extreme  severity.  One  striking  case  of  this 
type  was  a  railroad  inspector,  who  traversed  several  times  a  day 
alone  in  a  handcar  many  miles  of  railway,  and  yet  maintained  fair 
health,  much  to  the  astonishment  of  his  physician  and  myself.  1 
was  always  impressed  in  former  days  of  treatment  by  the  better 
results  frequently  obtained  by  ambulatory  as  compared  with  the 
hospital  treatment  at  that  time,  provided  the  same  degree  of 
attention  was  given  to  the  details  of  the  diet  and  hygiene  of  the 
patient.  According  to  the  result  of  recent  work  it  would  seem  now 
as  if  this  was  in  part  due  to  the  individual  maintaining  his  ordinary 
vocation,  and  thus  undergoing  considerable  muscular  work.  Finally 
I  have  looked  up  29  cases  of  diabetes  of  fifteen  or  more  years' 
duration,  and  in  many  of  these  it  is  apparent  that  considerable 
activity  has  been  maintained  throughout  life. 

Recently  Allen  and  DuKois'  have*  recorded  a  slight  rise  in  the 
respiratory  quotient  of  a  severely  diabetic  patient  undergoing  mild 
exercises  during  two  respiration  experiments.  Like  Benedict  and 
myself,  however,  they  draw  no  positive  deductions. 

Allen1  has  found  that  diabetic  dogs  with  a  known  constant  limit 
for  tolerance  of  carbohydrate  or  protein  upon  vigorous  exercise 

1  Nchrinir  and  Srlimnll:    Zisrhr.  f.  klin.  Mrd..  I '.107.  xxxi.  p.  .V.)   '.)_'. 

-  Molir:    L<>f.  fit.,  p.  '.Kill.      Sec  p.   IL'O. 

:;  Allen  and  DuBois:    Luc.  fit.,  p.  Klin. 

'Allen:    Ijo-toii  Mi-d.  and  Sur^.  .lour.,  l'.M.">,  clxxiii,  p.  74^. 


LOSS  OF  ENERGY  IN    THE    URINE  OF   DIABETICS        147 

in  a  treadmill  showed  a  marked  increase  in  tolerance,  as  demon- 
strated both  by  the  sugar  in  the  urine  and  in  the  blood.  lie  further 
says  that  dogs  which  have  for  months  regularly  shown  glycosuria 
whenever  they  were  given  100  grams  of  bread,  on  exercise  became 
able  to  take  200  grams  of  bread  as  a  regular  daily  ration  without 
glycosuria.  With  patients,  he  has  observed  results  sufficiently 
favorable  to  warrant  recommending  exercise  as  an  addition  to 
treatment,  and  lie  goes  on  to  say  that  in  a  patient  free  from  glyco- 
suria with  a  persistent  hyperglycemia,  one  fast  day  with  exercise 
may  reduce  the  blood  sugar  as  much  as  several  fast  days  without 
exercise.  Dr.  Allen  was  kind  enough  to  call  this  to  my  attention 
in  the  summer  of  1915,  and  I  am  able  to  confirm  his  statement. 
In  particular  I  have  noted  that  patients  have  retained  strength  and 
appeared  better  during  fasting  when  moderate  exercise  was  allowed 
than  when  they  remained  abed.  May  it  not  be  that  the  good 
results  of  treatment  which  are  often  obtained  with  children  are  in 
part  due  to  the  fact  that  they  exercise  far  more  than  adults?  On 
October  22,  191"),  I  observed  that  Case  No.  925,  aged  eleven  years, 
onset  one  month  previously,  was  tired  out  after  playing  tennis 
five  minutes,  although  eating  13  calories  per  kilogram  body  weight, 
but  on  October  25,  without  essential  increase  in  diet,  he  played 
tennis  for  half  an  hour  without  being  tired. 

H.     THE  LOSS  OF  ENERGY  IN  THE  URINE  OF  DIABETICS 
IN  THE  FORM  OF  SUGAR  AND  ACID  BODIES. 

Diabetic  patients  lose  a  considerable  percentage  of  the  energy 
of  their  food  by  the  excretion  of  sugar  and  acid  bodies  in  the  urine. 
The  enormous  draft  upon  the  food  supply  is  obvious  when  we  realize 
that  occasionally  even  as  much  as  680  grains  of  sugar  (2720  calories), 
and  100  grams  acid  bodies  (500  calories)  may  be  so  excreted.  This 
is  also  illustrated  by  Case  No.  235. 

TABLE  8(5. — CASK  2:>f).     MALE,  A<;ED  TWENTY-SEVEN  YEARS  AT  ONSET 
ix  1901.     No  HEREDITY.     WEICIIT,  (>">  KILOS,   FEBRUARY   17,  1909. 


Substance.  Grains. 

Protein         .      .  100  X  4 

Carbohydrate  no  X  4 

Fat   .     '.      .      .  220  X  9 

Alcohol  30  X  7 


2810  807 

2810  -  807  =  200)5  net  calories. 


The  diet  thus  furnished  only  (2003  -f-  05)  31  calories  per  kilo 
instead  of  an  apparent  (2810  4-  05)  43  calories  per  kilo  body  weight. 


14S     FACTORS   IX    THEATMEXT  OF   DIABETES   MELLITUH 

('use  No.  oil,  weighing  50.4  kilograms,  also  illustrates  the  groat 
loss  of  potential  energy  in  the  urine,  as  is  shown  from  the  following 
urinary  ana  lysis:  December  25  and  2(5,  I'.H  1 ,47(M)e.e. ;  specific  gravity, 
1027;  diaeetie  acid,  -\ — | — \-;  (8-oxybutyric  acid,  .14. X;  nitrogen,  14.5; 
ammonia,  total  (>..'>;  sugar,  copper  reduction,  1 XX  grains;  rotation,  !('»() 
grams.  Diet:  carbohydrate,!.'!");  alcohol, 45;  carbohydrate  balance 
—  55;  XaHCO.i,  2i>;  body  weight  without  clothing,  50.4  kilos.  It  will 
be  seen  that  1XX  X  4  =  752  calories  were  lost  in  the  urine  in  the  form 
of  sugar,  and  54. X  X  5  =  274  calories  in  the  form  of  /3-oxybutyric 
acid.  Case1  Xo.  205,  voided  on  October  2o-24,  11)00,  approximately 
10  liters  of  urine,  containing  GXO  grams  sugar,  equivalent  to  2720 
calories. 

I.     GLYCOSURIA  IS  THE  MOST  TRUSTWORTHY  SYMPTOM. 

In  most  chronic  diseases  there  is  no  criterion  by  which  the  success 
or  failure  of  treatment  can  be  readily  estimated.  Such  is  not  the 
case  in  diabetes.  One  can  toll  when  treatment  is  successful,  for  the 
patient  should  be  free  from  sugar  and  acid  and  be  happy  and 
vigorous.  While  the  twenty-four-hour  quantity  of  sugar  in  the  urine 
is  not  an  absolute  measure  of  diabetes,  still  in  the  vast  majority  of 
cases  it  is  an  accurate  index.  Taken  alone  the  quantity  of  sugar 
eliminated  is  not  of  great  significance,  still  less  the  percentage  of  a 
single  specimen,  but  when  compared  with  carbohydrate  intake  it  is 
possible*  to  determine  quite  definitely  the  condition  of  the  patient. 
I  should  deplore  that  anyone1  from  the  above  statement  should  lay 
undue-  stress  upon  this  sign,  because1  the  strength,  the1  weight,  the1 
me'iital  attitude,  the  pivse-ne-e  or  abse-nee  of  complications,  and  the- 
acidosis  are  all  important,  but  it  remains  true-  that  this  is  the1  erne1 
tVaturo  of  the1  disease  which  is  of  almost  mathematical  accurae-y, 
though  we1  often  err  in  thinking  of  it  alone1. 

The'  sugar  in  the-  urine"  of  diabe'tic  patients  usually  varies  diree-tly 
with  the-  quantity  of  carbohydrate-forming  mate'rial  in  the1  die't, 
to  a  lesseT  e-xtent  with  the1  protein,  but  is  uninfluenced  by  the-  fat, 
save-  as  that  influence's  the  total  calorie-  intake.  A  change  of  did 
is  shown  in  the1  urine  within  a  few  hours. 


J.     THE  NATURE  OF  DIABETIC  ACIDOSIS  AND  ITS  RELATION 

TO  COMA. 

1.  Acidosis  in  Normal  Individuals.-  If  a  healthy  individual  live-s 
for  three  siicce»ive  days  upon  a  carbohydrate-free  die't,  the1  urine- 
vended  upon  the  subsequent  morning  will  show  a  re-action  for  dia- 
evtie-  acid  with  the  feme-  chloride.  This  is  evidence  of  a  type-  of  acid 
intoxication  which  has  been  termed  bv  Xaunvn  "  acidosis."  Acidosis 


NATURE  OF  DIABETIC  ACIDOSIS  149 

is  represented  by  three  bodies:  /3-oxybutryic  acid  (CII3.CIIOII.- 
CILCOOII),  diacetic  acid  (CH3.CO.CH2COOH),  and  acetone 
(CII3.rO. CII3),  all  of  which  are  excreted  in  the  urine,  and  the  latter 
in  the  breath  as  well. 

Acidosis  is  still  more  simply  produced  in  normal  individuals  by 
fasting,  but  it  is  of  a  milder  type.  Thus  Benedict's  subject  at  the 
Nutrition  Laboratory  constantly  showed  an  acidosis  during  his 
fast  of  thirty-one  days. 

1  welcome  the  opportunity  to  call  to  the  attention  of  physicians 
the  records  of  this  case  of  fasting  which  are  more  complete  than 
those  reported  for  other  fasting  individuals. 

This  subject  took  only  900  c.c.  of  distilled  water  daily  by  mouth 
and  during  the  thirty-one  days  of  the  fast  lost  13.25  kilograms  or 
21  per  cent,  of  his  normal  weight.  Of  this  quantity,  55  per  cent, 
was  computed  as  due  to  water,  2  per  cent,  to  stored  glycogen 
13  per  cent,  to  protein  and  27  per  cent,  to  fat.  The  remaining 
405  grams  (3  per  cent.)  was  attributed  to  loss  of  mineral  salts.  The 
blood-pressure  fell  30  mm.  mercury.  In  the  four  days  prior  to  the 
fast  the  pulse-rate  varied  between  82  and  70,  during  the  first  four 
fasting  days  between  68  and  02,  and  in  the  last  four  days  between 
59  and  57.  So  soon  as  the  percentage  of  carbohydrate  in  the  com- 
bined carbohydrate  and  fat  of  the  body  metabolized  fell  below 
12  percent,  acidosis  was  marked  but  eventually  no  carbohydrate 
was  burned  and  yet  the  acidosis  markedly  decreased. 

From  the  first  to  the  third  day  from  10  to  11)  per  cent,  of  the 
heat  was  derived  from  glycogen,  but  between  the  third  and 
thirteenth  days  this  fell  to  1  and  3  per  cent,  and  after  this  day 
entirely  ceased. 

The  acidosis  in  this  man  was  demonstrated  by  estimations  of  the 
carbon  dioxide  tension  of  the  alveolar  air,  the  ammonia-nitrogen, 
and  the  /3-oxybutyric  acid.  During  these  thirty-one  days  the 
lowest  point  reached  by  the  carbon  dioxide  tension  was  26.8  mm., 
the  highest  ammonia-nitrogen  was  1.91  grams  upon  the  sixteenth 
day,  the  /3-oxybutyric  acid  reached  (i.9  grams  upon  the  twenty- 
fourth  day.  (See  Table  87  on  pages  150  and  151.) 

It  is  of  interest  that  the  acidosis  during  prolonged  fasting  in  a 
healthy  individual  does  not  notably  increase  with  the  continuation 
of  the  fast,  but  it  is  still  more  interesting,  in  the  light  of  the  behavior 
of  acidosis  in  fasting  diabetics  to  be  described  later,  that  it  should 
not  at  length  entirely  disappear. 

The  effect  upon  the  acidosis  of  prolonged  fasting  in  obesity  is 
not  known,  but  during  the  first  four  days  of  the  fast  of  a  fat  young 
woman  Folin  and  Denis1  found  that  there  was  a  notable  increase. 
This  is  shown  in  Table  88. 

1  Folin  and  Denis:  Jour.  Biol.  Them.,  1915,  xxi,  p.  183. 


(  150  ) 


>.CO 

r^ 

co  x 

OM 

1 

^"S 

X 

t^  O 

CO 

c 

o 

>£• 

c-i 

,~ 

en 

-7 

t>.  ^5 

>v 

C3 

<*<  ~ 

t^ 

C 

-  7  — 

CO  _ 

>i~ 
.27 

6 

^.  o 

t^ 

>.>i 

S  '-.? 

-t  c 

^5™ 

t^  ~ 

co" 

•*•"  _ 

ST.  C 

^  X 

^•2R 

t^ 

ic 

£2* 

£- 

^  j  x 

<"-  M  ' 

X 

*r 

co  ~: 

-,  C^l 

tr  r~ 

r-«-t 

*        * 

^  t~- 

c^r  ^c  » 

'<- 

X 

S  =  : 

•-i         t^  tc  1.1      -^  s      ox     I-H  --c  x  s  co  r-i  i  .i      x 

•  c-i 

H  rt  COOOOC        O 


x  --r;      c-t  f          f  co  c  x  co 


EH 


Sit-       CO—       t^        X  —  "~  —  —        1^       ~] 

.  t-      _•        .    .    .    .     .       _. 


•M     .  c;  c:  M      i^ 

.1         ...          __._._ 
I  — <      ~?  "<          ~-c~_, 

•M  -   r!—    -  ^ 

..^   r3 


—  >~       C-l  C  -?       O  i-l       C;  t~       VC:  C-l       t^       CO  —  l^  —   S        I-       -H       C-l       2TI'~  —        •        —  O      i      °  2   "C~   2 

""      _•    '  -  ' '~     _'._''_•'      _•       '       '•""_: ri        M     c-i       -co        x _£  ^  2  £ 

i-  CO        CO  ?l  ~        J^  "1  C-l  —  —    C~   a 


152     FACTORS  IX   TREATMEXT  OF  DIABETES  MELLITUS 

TABLE  88. — THK  Acinosis  OF  A  FAT  WOMAY  nrui.\<;  THREE  PERIODS 

OK  FASTI \<;   (Foi.i.v  AND  DEXIS). 


Day.           cms. 
1            0.01 

cms. 
0.27 

0 

c 
I) 

11 

230 

0 

is.                      Remarks. 
Feeling  well. 

2           0 

.OS 

1  .12 

2.00 

0 

7:5 

150 

5.2          Slight  headache. 

3           0 

.  10 

1  .  .J7 

17.01 

1 

87 

508 

21. 

0 

Severe 

headache. 

1           0 

.  ss 

2.  10 

is.  47 

~2 

50 

(  05 

49. 

5 

Heada< 

he,  nausea, 

and  ( 

lizziness. 

15 

0 

0 

0 

0 

31 

ISO 

0 

Feeling 

well. 

10           0 

.02 

0 

0 

0 

37 

200 

0 

Feeling 

well. 

17          0 

o:; 

1  .17 

0.  17 

0 

53 

335 

30 

0 

Feeling 

well. 

IS           0 

35 

1  .  10 

5.44 

I 

01 

505 

32. 

0 

Slight 

headache, 

nans 

•a. 

10          0 

.-1(1 

1.15 

13.54 

1 

50 

055 

45 

0 

Headac 

he,  nausea, 

and  ( 

lizziness. 

24 

0 

0 

0 

0 

50 

1  15 

0 

Feeling 

well. 

25 

0 

0 

0 

0 

37 

100 

0 

Feeling 

well. 

20          0 

04 

0.37 

0.1S 

0 

51 

210 

GO  . 

0 

Feeling  well. 

27          0 

20 

1  .  30 

17.34 

0 

SI 

300 

24. 

0 

Headai 

he,  nausea. 

The  subjective  symptoms  disappeared  as  if  by  magic  as  soon  as 
the  patient  began  to  partake  of  food.  A  single  piece  of  toast  with 
a  cup  of  coffee  at  once;  restored  the  patient  and  kept  her  perfectly 
cheerful  for  several  hours. 

The  marked  acidosis  presented  by  this  fat  woman  is  in  distinct 
contrast  to  the  slight  acidosis  obtained  in  Benedict's  normal  sub- 
ject, and  suggests  the  importance  of  fat  in  bringing  this  about. 
Xo  less  striking  is  the  tendency  of  the  acidosis  to  become  less 
during  successive  periods  of  fasting  and  later  this  will  be  seen  to 
be  of  great  therapeutic  significance. 

The  amount  of  acidosis  thus  far  described  is  much  below  that 
produced  when  an  individual  is  placed  upon  a  diet  from  which  carbo- 
hydrate is  wholly  excluded.  In  the  classical  experiment  of  Gerhard 
and  Schlesinger  \)  grams  of  /3-oxybiityric  acid  were  demonstrated 
in  1  .">()()  c.c.  of  urine  while  they  were  living  upon  a  fat-protein  diet, 
and  Benedict  and  I1  obtained  S  grams  of  /3-oxybutyric  acid  and 
4.07  grams  ammonia  in  the  urine  of  a  healthy  student  who  had 
been  upon  such  a  diet  for  three  days.  If  the  quantity  of  fat  in  the 
fat-protein  diet,  is  increased  there  is  a  simultaneous  increase  in  the 
excretion  of  acetone  and  /3-oxybutyric  acid.  Thus  Satta-  found  the 
following  changes  during  four  days  when  a  normal  individual  was 
taking  L'OO  to  MOO  u-rams  of  fat  and  I'OO  to  LV>0  "Tains  of  meat: 


NATURE  OF  DIABETIC  ACIDOSIS  153 

TABLE  89. — ACIDOSIS  OF  A  NORMAL  IN-DIVIDUAL  n>ox  A  FAT-J-ROTKIX 

DIET. 

Day.  Acetone.  /3-oxybutyric. 

1  ...            0.0(52  0.84 

2  ...            .            0.0(50  0.73 

:$ 2.5.50  :i..5« 

4 3.110  14.70 

Landergren1  still  further  increased  the  acidosis  by  combining 
muscular  work  with  the  diet.  I5y  this  means  not  only  was  the 
carbohydrate  in  the  diet  excluded,  but  the  carbohydrate  stored  in 
the  body  in  the  form  of  glycogen  was  rapidly  depleted,  and  so  not 
available  for  counteracting  the  acidosis. 

Forsner,2  by  forcing  up  the  limits  of  fat  in  the  diet,  obtained  an 
excretion  of  42.8  grams  of  acid  bodies  in  one  day,  and  even  when 
the  diet  contained  40  grams  of  carbohydra-te  the  artificial  acidosis 
remained  as  high  as  32.3  grams. 

Aside  from  the  acid  bodies  eliminated  in  the  urine,  mention  has 
been  made  of  acetone  excreted  from  the  lungs,  but  this  is  probably 
not  very  considerable.  Thus,  it  is  estimated  that  a  normal  individual 
will  excrete  0.013  gram  acetone  in  twenty-four  hours  from  the 
kidneys,  but  only  0.0038  gram  from  the  lungs.  After  the  adminis- 
tration of  90  grams  of  oleic  acid  to  a  fasting  man  I  found  0.847 
gram  of  acetone  in  the  breath  and  0.185  gram  in  the  urine  during 
twenty-four  hours.3 

Sassa4  found  traces  of  /3-oxybutyric  acid  in  health  in  the  blood  of 
men  and  animals  amounting  to  0.01  to  0.02  per  cent.  In  diabetic 
coma  the  percentage  may  reach  eight  times  the  normal  figures. 

Just  as  Landergren  was  able  to  increase  the  production  of  acid 
bodies  by  depleting  the  glycogen  storage,  through  muscular  exercises, 
so  S.  R.  Benedict  has  succeeded  in  doing  the  same  with  phlorhi/in. 
In  an  experimental  period  of  about  two  weeks,  during  which 
phlorhizin  was  injected  to  prevent  the  oxidation  of  sugar  through 
the  breaking  down  of  protein  the  subject  excreted  32  grams  of 
pi-oxybutyric  acid  per  day,  and  during  the  whole  period  over  300 
grams.5 

Experiments  of  this  nature  have  been  interpreted  as  showing 
the  similarity  of  the  acidosis  of  normal  individuals  to  that  which 
is  seen  to  occur  in  diabetic  individuals,  and  furthermore  that  the 
absence  of  the  combustion  of  carbohydrate  is  an  important  factor 
in  acidosis.  AVhether  such  a  conclusion  is  justifiable  has  been 
recently  placed  in  doubt  by  experiments  upon  severe  cases  of  diabetes 

1  Landorgren:    Xord.  mod.  Ark.,  1910,  ii,  p.  1. 

2  Forsner:    Arch.  Skaiulin.  f.  Phys.,  1910.  xxiii,  p.  305. 
3Joslin:    Jour.  Mod.  Research,  1904,  vii,  p.  433. 

«  Sassa:    Bioehem.  Ztschr..  1914,  lix,  p.  3f>2. 

6  Benedict:    Proc.  Soc.  Exp.  Biol.  anil  Mod.,  1914,  xi,  p.  134. 


1.V4     FACTORS   IX    TREATMENT  OF   DIABETES   MKLLITUS 

with  little  or  no  tolerance  for  carbohydrate,  who,  upon  fasting 
become  entirely  free  from  acidosis.  The  question,  however,  is  not 
wholly  settled,  because  our  present  methods  of  determining  the 
respiratory  quotient  are  not  sufficiently  exact  to  absolutely  exclude 
the  possibility  of  the  combustion  of  small  quantities  of  carbohydrate, 
for  instance  at  the  rate  of  1  gram  of  carbohydrate  per  hour  for  the 
twenty-four  hours.  I'ntil  lately  it  has  appeared  safe'  to  say  with 
Landergren  that  the  diabetic  acidosis  is  due  not  so  much  to  a  loss 
of  power  to  burn  carbohydrate,  but  rather  to  the  fact  that  the 
diabetic  patient  has  no  carbohydrate  to  burn.  Today  we  cannot 
be  so  dogmatic,  for  the  patient  may  have  carbohydrate  to  burn 
of  which  we  have  not  been  aware,  and  it  is  certain  that  the  fat 
metabolism  plays  a  more  prominent  part  in  the  acidosis  problem 
than  has  been  supposed. 

(a)  Adaptation  of  the  Body  to  a  Non-carbohydrate  Diet  and  to 
Acidosis. — The  Kskimos  have  always  been  a  pu/xle  to  those1  who 
explain  the  presence  of  acidosis  as  due  to  the  absence  of  carbo- 
hydrate in  the  diet.  It  is  possible,  however,  that  the  Kskimos 
obtain  more  carbohydrate1  than  we  have  thought,  and,  furthermore, 
the  quantity  of  protein  in  their  diet  is  sufficiently  large  to  furnish 
notable  quantities  of  carbohydrate.  It  has  been  repeatedly  shown 
that  large  quantities  of  protein  will  restrict  the  development  of 
acidosis  in  normal  individuals  on  a  protein-fat  diet.  Another 
instance  of  adaptation  is  furnished  by  the  experiment  of  the  fasting 
man  at  the  Nutrition  Laboratory.  During  the  progress  of  his 
fast  the  acidosis  increased  for  a  time,  then  was  practically  at  a 
stand-still,  and  decreased  in  the  latter  days  of  the  fast.1  It  is  reason- 
able to  conclude  that  the  body  of  the  fasting  man  adapted  itself 
to  the  changed  conditions  and  in  some  way  restricted  the  output 
of  acid  bodies.  This  may  be  the  explanation  of  the  lack  of  acidosis 
among  the  Ivskimos.  Finally  the  case  of  the  fat  woman  studied  by 
Folin  and  Denis,  and  already  cited  on  page  1.12,  beautifully  illus- 
trates this  point.  This  power  of  adaptation  is  certainly  an  important 
factor  to  bear  in  mind,  because  it  shows  that  by  training  it  may 
not  be  dangerous  to  keep  a  diabetic  patient  on  a  non-carbohydrate 
diet  for  a  prolonged  period. 

Changes  in  the  carbohydrate  and  water  content  of  the  diabetic 
organism  occur  so  rapidly  that  they  are  often  overlooked,  and  yet 
these  may  be  of  great  importance  in  influencing  the  acidosis. 

The  quantity  of  carbohydrate  which  ordinarily  must  be  oxidized 
to  prevent  the  appearance  of  acidosis  in  the  healthy  individual  is 
approximately  KH)  grams.  This  statement  in  this  form  is  really 
incomplete  for  it  is  necessary  to  know  the  amount  of  fat  which  is 


NATURE  OF   DIABETIC   AC  I  DOM  K  155 

simultaneously  ingested.  The  quantity  of  protein  metabolized 
is  also  of  great  significance,  for  from  every  100  grains  of  protein 
approximately  GO  grams  of  carbohydrate  may  be  formed.  Acidosis 
may  disappear  when  the  body  has  been  trained  to  live  upon  a  diet 
containing  less  carbohydrate,  but  with  this  exception  the  presence 
of  acid  bodies  in  the  urine  accompanies  a  lowering  of  combustion  of 
carbohydrate  in  the  body.  It  makes  no  difference  whether  the 
lowering  of  combustion  is  due  to  the  lack  of  carbohydrate  in  the 
diet,  to  fasting,  starvation,  or  to  lack  of  carbohydrate  which  occurs 
in  the  malnutrition  of  cachexia  or  the  increased  metabolism  of  fever. 
The  absence  of  food,  together  with  disturbances  in  the  metabolism 
of  fat,  probably  accounts  for  the  frequent  acidosis  in  the  gastro- 
intestinal diseases  of  children. 

(6)  Source  of  the  Acid  Bodies. — The  source  of  the  acid  bodies  is 
evidently  not  in  carbohydrate.  Of  the  remaining  two  foodstuffs, 
it  has  already  been  shown  that  an  increase  in  the  administration  of 
fat  leads  to  an  increased  acidosis,  and  there  is  no  question  but 
that  fat  is  the  chief  source  of  /3-oxybutyric  acid.  Each  molecule 
of  a  higher  fatty  acid,  as  it  is  broken  down  to  a  lower,  provided  it 
has  an  even  number  of  carbon  atoms,  leads  to  the  production  of  one 
molecule  of  /3-oxybutyric  acid,  though  upon  this  point  there  is  not 
complete  unanimity.  As  a  matter  of  fact,  the  only  fatty  acids  which 
are  present  in  the  body  are  those  containing  an  even  number  of 
carbon  atoms.  It  has  been  estimated  that  out  of  210  grams  of  fat, 
72  grams  of  (3-oxybutyric  acid  may  be  produced.1  Notable  quan- 
tities of  /3-oxybutyric  acid,  however,  can  also  be  formed  from  pro- 
tein. Thus,  from  120  grams  protein  I->Gto40  grams  of  /3-oxybutyric 
acid  may  theoretically  be  obtained.  It  is  interesting  that  those 
amino-acids  of  the  protein  molecule  which  lead  to  the  production  of 
/3-oxybutyric  acid  do  not  produce  sugar,  and  conversely,  that  those 
which  lead  to  the  formation  of  sugar  produce  no  /3-oxybutyric  acid 

(c)  The  Percentage  Relation  of  Acid  Bodies  to  One  Another. — The. 
interrelation  of  acetone,  diacetic  acid,  and  /3-oxybutyric  acid  to 
one  another  must  be  very  intimate.  Netibauer2  considers  that  there 
is  a  reversible  action  between  diacetic  acid  and  /3-oxybutyric  acid, 
and  that  these  readily  change  back  and  forth  with  one  another.  It 
is  thought  by  some  that  there  is  a  fixed  proportion  between  these 
acids,  varying  with  different  patients  but  constant  in  the  same 
patient.  Folin3  is  inclined  to  doubt  the  existence  of  preformed 
acetone  in  the  body,  but  explains  its  presence  in  the  urine  as  a 
decomposition  product  of  diacetic  acid.  At  any  rate,  acetone 


1  Magnus-Levy,  in  Spcz.  Path.  u.  Therap.  inn.  Krunk.,  Kraus  u.  Brugsch,  Berlin, 


2  Nenbauer:    Verhnrd.  <1.  Kong.  f.  inn.  Mod.,  1010,  xxvii,  p.  5GG. 


Folin:    Jour.  Biol.  Chem.,  1907,  iii,  p.  177. 


Ml)     FACTORS   IX    TRKATMKXT  OF   DIAHETES   MEELITCS 

seldom  constitutes  over  a  small  percentage  of  the  total  acidosis,  and 
acetone  and  diacetic  acid  combined  not  over  )>()  per  cent. 

(tl)  Mode  of  Elimination  of  Acid  Bodies. — Practically  all  the  acid 
bodies  are  eliminated  by  the  kidneys.  Only  one  of  these — acetone  - 
is  excreted  by  the  lungs,  and  the  amount  must  be  small.  In  experi- 
ments upon  a  healthy  man  following  the  feeding  of  oleic  acid,  I 
obtained  an  excretion  of  O.M7  gram  acetone  calculated  for  the  24 
hours  in  the  breath.  The  method  of  estimation  of  the  acetone  in  the 
breath  was  not  very  satisfactory,  and  it  would  be  advantageous  to 
institute  a  series  of  experiments  of  this  nature  on  a  larger  scale.  The 
oilier  two  bodies  are  excreted  as  salts  and  even  as  free  acid  in  the 
urine.  Magnus-Levy1  found  that  the  concentration  of  these  acids  in 
the  urine  seldom  rose  above  1.5  per  cent.,  and  lie  never  encoun- 
tered out  of  <  oma  values  greater  than  (>.(>  per  cent.  It  is  evident, 
therefore,  that  the  elimination  of  the  acid  bodies  is  closely  con- 
nected with  the  quantity  of  water  excreted.  It  is  also  dependent 
upon  the  available  alkali,  for  it  is  universally  recognized  that 
in  severe  acidosis  the  quantity  of  /3-oxybutyric  acid  in  the  urine 
rises  when  alkalis  are  given.2  I  do  not,  however,  remember  data  in 
the  literature  which  show  an  increased  elimination  of  acid  bodies 
following  the  administration  of  alkalis  to  a  normal  individual  with 
experimental  acidosis.  Such  would  be1  valuable. 

It  would  be  wrong  to  consider,  however,  that  the  only  method 
the  body  had  by  which  to  free  itself  of  acid  was  by  the  kidneys. 
The  body  has  a  most  efficient  pathway  in  the  lungs  through  which 
carbonic  acid  is  constantly  removed  from  the  body.  In  fact,  so 
soon  as  this  acid  begins  to  increase  in  the  tissue's,  it  also  rises  in 
the  blood,  this  stimulates  the  respiratory  center  with  resulting 
hyperpnea  and  the  excess  of  carbonic  acid  is  removed  by  the 
increased  ventilation.  The  total  quantity  of  carbon  dioxide*  for  the 
twenty-four  hours  is  not  increased  save  for  the  increase  due  to  the 
increased  metabolism  which  accompanies  acidosis,  and  indeed  the 
percentage  of  carbon  dioxide  in  the  alveolar  air  is  actually  diminished 
because  it  is  diluted  in  consequence  of  the  increased  ventilation. 

'2.  Acidosis  in  Diabates. --(a)  Similarity  to  that  in  Normal  Indi- 
viduals. The  acidosis  of  diabetic  individuals  differs  in  no  particu- 
lar from  that  of  normal  individuals  except  in  degree,  and  even 
this  limitation  may  be  overcome  in  a  normal  inrhvidu:il  placed 
on  a  carbohydrate-free  diet  with  a  forced  feeding  of  fat  and  much 
exercise.  Whereas  in  normal  individuals  the  acidosis  seldom 
exceeds  a  few  grams,  in  diabetic  individuals  it  often  reaches  hundreds 
of  gran>.  Thus,  C'ase  No.  -I,  male,  onset  at  fifteen  vears  of  age, 


NATURE  OF  DIABETIC  ACIDOSIS  157 

without  diabetic  heredity,  excreted  three  years  and  two  months 
later,  in  three  successive  days  of  coma,  4o7  "Tains  /3-oxybutyric 
acid  as  calculated  from  the  excess  of  bases  in  the  urine  or  )>">(> 
grams  acid  bodies,  calculated  from  (3-oxybutyric  acid  and  diacetic 
acid  extracted  from  the  urine.  Just  as  in  normal  individuals  the 
presence  of  these  bodies  implies  non-combustion  of  or  combustion 
of  insufficient  carbohydrates,  in  diabetic  individuals  the  presence 
of  these  bodies  implies  non-combustion  of  or  combustion  of  insuffi- 
cient carbohydrate  material.  But  it  is  easier  for'a  diabetic  individual 
to  acquire  an  acidosis,  because  most  of  the  carbohydrate  which  he 
eats  is  lost  to  his  metabolism.  If  the  diet  of  the  diabetic  individual 
is  unrestricted,  he  often  eats  so  large  a  quantity  of  carbohydrate- 
forming  material  that  enough  of  it  is  oxidized  to  prevent  the  occur- 
rence of  these  bodies:  Thus  Case  No.  295,  male,  onset  at  sixteen 
years,  seven  years  later  excreted  10, 000  c.c.  of  urine  containing 
GSO  grams  of  sugar,  and  yet  failed  to  show  a  positive  reaction  for 
diacetic  acid.  When  the  carbohydrates  in  his  diet  were  restricted 
to  even  280  grams,  acidosis  appeared;  when  the  diet  was  still  further 
restricted,  the  acidosis  became  extreme.  Just  as  normal  individuals 
vary  according  to  the  ease  with  which  an  acidosis  is  produced  and 
the  extent  of  the  same,  so  do  diabetic  individuals.  Very  likely 
this  will  eventually  be  explained  by  the  extent  of  the  carbohydrate 
and  fat  storage  of  the  different  individuals,  as  well  as  by  the  storage 
of  alkalis  and  water  which  plays  such  an  important  factor  in  the 
elimination  of  acid  bodies. 

(6)  Extent  of  Acidosis  in  Mild,  Severe,  and  Extreme  Cases. — The 
acid  bodies  which  make  up  the  acidosis  of  diabetes  are  constantly 
being  produced  and  constantly  being  excreted. 

A  moderate  acidosis  represented  by  the  excretion  of  5  to  10 
grams  /3-oxybutyric  acid,  the  elimination  of  2  grams  ammonia,  or 
a  fall  of  carbonic  acid  in  the  alveolar  air  to  4  per  cent.,  or  29  mm. 
mercury  may  or  may  not  be  harmful  to  an  individual.  So  far  as 
my  experience  goes  such  moderate  quantities  of  acid  products 
are  of  little  significance  in  cases  of  long  duration,  but  this  is  not 
true  of  those  patients  who  have  recently  acquired  an  acidosis  for 
the  first  time.  This  does  not  prove  that  these  bodies  are  not  harm- 
ful, but  that  they  are  a  useful  sign  of  a  condition  which  ought  to 
be  remedied  for  fear  it  will  grow  worse,  rather  than  that  they  are 
actually  harmful.  When  the  quantity  of  acid  is  present  in  double 
this  amount,  diabetic  patients  invariably  show  that  they  are 
burdened  with  disease,  but  it  would  be  unfair  to  attribute  this 
state  to  the  acidosis  alone,  and  not  to  the  neglected  disease  itself. 
In  former  days,  when  the  acidosis  of  patients  was  not  controlled, 
over  and  over  again  1  saw  diabetic  cases  who  carried  an  acidosis  of 
4  grams  ammonia  for  years,  with  only  gradually  declining  health. 


158     FACTORS  IN   TREATMENT  OF  DIABETES  MELLITUS 

Even  so  extreme  a  ease  of  diabetes  as  Case  No.  344,  eight  years 
after  onset  showed  51.5,  52.0,  52.0,  and  .14. <S  grains  /3-oxybutyric 
aeid  respectively  on  four  different  days,  and  yet  travelled  safely  for 
thousands  of  miles,  dying  of  tuberculosis  without  coma  four  months 
later.  But  it  may  be  considered  that  the  acidosis  is  severe  whenever 
/3-oxybutyric  acid  reaches  an  excretion  of  .'50  grams  in  twenty-four 
hours,  the  ammonia  5  grams,  or  when  the  carbon  dioxide  tension 
of  the  alveolar  air  is  o  per  cent,  the  equivalent  of  a  pressure  of 
22  mm.  Hg.  The  large  quantity  of  o5(>  grams  /3-oxybutyric  acid 
(if  calculated  by  excess  of  bases  4o7  grams)  already  mentioned  as 
excreted  by  Case  Xo.  4,  during  three  days  of  coma  is  nearly  the 
maximum  found  in  the  literature.  This  is  equivalent  to  the  elimina- 
tion of  o  grams  per  kilo  body  weight  daily  for  three  days  for  an 
individual  weighing  50  kilograms,  or  if  the  acidity  is  expressed  in 
terms  of  hydrochloric  acid  approximately  1  gram  per  kilo.  Xaunyn 
estimates  the  quantity  of  /3-oxybutyric  acid  in  the  tissues  of  a 
patient  near  coma  at  between  200  and  .')()()  grams. 

/3-oxybutyric  acid  circulates  in  the  blood  combined  with  alkali 
as  a  salt,  but  the  acid  is  excreted  in  the  urine  to  a  large  extent  as 
free  acid  and  the  base1  retained  in  the  body.  It  is  only  when  much 
alkali  is  given  that  the  large  quantities  of  /3-oxybutyric  acid,  such 
as  were  excreted  by  Case  Xo.  4  during  coma,  are  found.  The 
formation  of  acid  never  goes  on  to  such  a  degree  that  the  blood 
shows  an  acid  reaction.  Such  a  condition  is  incompatible  with  life. 
In  fact,  so  constant  is  "the  reaction  of  the  blood  that  a  change 
from  the  reaction  of  ordinary  tap  water,  which  is  more  alkaline  than 
the  blood,  to  that  of  distilled  water,  which  is  much  more  acid  than 
blood,  would  be  fatal."  If  the  blood  were  acid,  the  carbonic  acid 
would  be  displaced  from  its  combination  with  an  alkali  by  the 
stronger  /3-oxybutyric  acid  and  set  free  in  every  cell  of  the  body, 
and  no  alkali  would  be  available  to  combine  with  it  and  take  it 
back  to  the  lungs  for  elimination.  The  normal  blood  and  respiratory 
exchange  is  represented  by  the  following  formula:  2XaIICO;i  = 
Xa2CO3  +  CO,  +  II,(). 

The  above  formula  clearly  shows  how  easy  it  is  for  /3-oxybutyric 
acid,  which  is  stronger  than  carbonic  acid,  to  sei/e  upon  free  alkali 
and  thus  hamper  the  removal  of  carbonic  acid  from  the  tissues. 

Henderson,  at  the  meeting  of  the  Association  of  American 
Physicians,  in  Washington,  in  19 Hi,  said:  "Any  modification  of  the 
normal  equilibrium  between  acids  and  bases  within  the  organism 
whereby  the  power  to  neutralize  acid  is  diminished  is  to  be  regarded 
as  a  condition  of  (letdown. 

"What  is  essential  and  common  to  all  conditions  of  acidosis  is  a 
depletion  of  the  alkali  of  the  body.  This  involves  at  least  a  diminu- 
tion of  the  bicarbonatcs  of  the  blood,  and  in  severe  cases  it  probably 


XATUIiE  OF   DIABETIC   ACIDOMS  159 

involves  the  draining  away  of  very  large  quantities  of  alkali  from 
many  sources. 

"Nothing  is  simpler  than  the  process  by  which  this  condition  is 
established.  If  an  acid  is  poured  into  an  aqueous  solution  of 
carbonic  acid  in  equilibrium  with  the  air,  to  which  a  certain  amount 
of  a  bicarbonate  has  previously  been  added,  the  acid  will  react, 
according  to  its  concentration  and  avidity  for  base,  to  a  greater  or 
less  degree  with  the  bicarbonate,  forming  in  due  amounts  its  own 
salt  and  free  carbonic  acid,  which  must  escape  into  the  air,  since  the 
solution  is  already  in  equilibrium  with  the  carbonic  acid  of  the 
atmosphere.  Thus,  for  instance,  a  solution  of  sodium  bicarbonate 
to  which  half  of  the  equivalent  amount  of  hydrochloric  acid  has 
been  added  will  in  the  course  of  time  contain  just  as  much  free 
carbonic  acid  as  it  did  before  and  just  half  as  much  bicarbonate. 
Now  the  laws  governing  the  equilibria  between  acids  and  bases 
determine  the  fact  that  it  is  in  like  manner  chiefly  bicarbonates  which 
react  with  acids  introduced  into  the  blood,  and  when  the  resulting 
carbonic  acid  has  been  liberated  by  the  lung  the  result  is  very 
similar  to  that  of  the  simple  chemical  experiment.  It  is  to  be 
observed,  however,  that  the  respiratory  process  tends,  under  these 
circumstances,  to  eliminate  more  than  the  newly  liberated  carbonic 
acid;  the  tension  of  carbonic  acid  in  the  blood  is  thus  diminished 
nearly  in  proportion  to  the  diminution  of  bicarbonates,  and  since 
the  hydrogen-ion  concentration  is  proportional  to  the  ratio  of  the 
free  carbonic  acid  to  the  bicarbonates,  the  degree  of  alkalinity  of  the 
blood  is  unchanged  by  the  introduction  of  acid — hence  the  theory 
that  the  hydrogen  or  hydroxyl  ion  is  the  hormone  of  respiration— 
but  tlie  eijiiilibriuni  is  changed. 

"The  condition  of  acidosis,  simple  though  it  may  be  in  its  essential 
features,  is  physiologically  of  the  greatest  complexity;  for  the  acid- 
base  equilibrium  is  involved  in  a  great  variety  of  other  equilibria, 
such  as  those  of  osmotic  pressure  and  volume;  it  influences  the 
distribution  of  electrolytes  between  corpuscles  and  plasma,  the  state 
of  colloids,  hence  perhaps  the  union  of  oxygen  and  hemoglobin;  it 
modifies  the  activity  of  enzymes;  and  it  is  probably  involved  in 
many  undiscovered  phenomena.  It  modifies,  moreover,  the  general 
metabolism  and  the  activities  of  lung  and  kidney.  Here  are  prob- 
lems enough  to  occupy  many  years  of  research,  and  I  have  no  doubt 
that  the  results  of  these  researches  will  advance  the  science  of 
medicine." 

The  method  by  which  the  blood  retains  its  alkalinity  is  admirably 
described  by  Rowland:1 

"The  important  constituents  of  the  blood  so  far  as  the  regulation 

'Rowland:    Bull.  Johns  Hopkins  Hospital,  1916,  xxvii,  p.  03. 


1(K)     FACTORS  IX   TREATMEXT  OF  DIABETES  MELLITUS 

of  the  reaction  is  concerned  are  (a)  sodium  bicarbonate,  occurring 
both  in  the  plasma  and  in  the  cells,  (/;)  the  acid  and  alkaline  phos- 
phates of  potassium,  found  almost  entirely  within  the  red  blood 
cells,  and  (r)  the  proteins. 

"Considering  the  blood  first  as  a  solution  of  bicarbonates:  A 
la  rue  amount  of  acid  (carbonic-  acid)  is  constantly  being  formed  in 
the  tissues.  It.  must  be  removed  by  the  lungs,  but  first  it  must  be 
transported  to  the  lungs  by  the  blood.  This  stream  of  acid  which, 
with  an  adult,  in  the  course  of  the  day,  is  the  chemical  equivalent 
of  several  hundred  cubic  centimeters  of  concentrated  hydrochloric 
acid,  is  sufficient  to  render  acid  any  ordinary  solution  and  keep  it 
permanently  acid.  If  this  should  happen  in  the  blood,  life  would 
of  course  be  impossible,  but  owing  to  the  laws  that  govern  the 
reaction  of  solutions  of  weak  acids  and  their  salts,  the  solutions  of 
bicarbonate  are  able  to  take  up  the  quantity  of  the  acid,  carbon 
dioxide,  without  appreciably  undergoing  a  change  in  reaction.  Thus 
there  can  be  transported  from  the  tissues  to  the  lungs  and  so  con- 
tinuously eliminated  from  the  body,  a  very  large  amount  of  acid. 
This  steady  escape  of  acid  is  accomplished  with  no  harm  and  with 
no  strain  upon  the  organism.  The  respiratory  center  is  adjusted 
to  assist  in  the  removal  of  the  carbon  dioxide.  If  there  were  no 
respirations  and  circulation  were  continued,  eventually  the  carbon 
dioxide  concentration  would  be  the  same  in  the  tissues,  in  the  blood, 
in  the  air  and  in  the  pulmonary  alveoli. 

"  But.  the  respirations  lower  the  concentration  in  the  lungs  and 
thus  allow  the  carbon  dioxide  to  escape  from  the  tissues  where  the 
concentration  is  highest,  by  the  blood  where  the  concentration  is 
lower,  to  the  air  in  the  lungs  where  the  concentration  is  lowest. 
The  respiratory  center  is  extraordinarily  sensitive  to  the  slightest 
alteration  in  the  reaction  of  the  blood  toward  the  acid  side,  so 
that  an  increased  production  of  carbon  dioxide  in  the  tissues,  such 
as  occurs,  for  instance,  with  muscular  exercise,  and  the  resultant 
slight  excess  in  the  blood  is  answered  by  an  increased  ventilation 
of  the  lungs  which  removes  the  carbon  dioxide,  thereby  bringing 
the  reaction  of  the  blood  back  to  normal.  Other  acids,  whether 
formed  in  the  body  or  introduced  from  outside,  produce  a  similar 
effect.  They  displace  the  carbonic  acid  from  the  sodium  bicarbonate 
and  set  the  carbon  dioxide  free.  This  excess  of  carbon  dioxide  is 
removed  by  the  increased  pulmonary  ventilation,  leaving  a  neutral 
>alt,  sodium  oxybutyrate,  or  chloride  or  what  not  to  be  removed 
by  the  kidneys.  Such  a  mechanism  allows  relatively  huge  amounts 
of  abnormal  acids  to  be  at  once  rendered  innocuous  and  removed; 
for  instance,  XallCO,  +  IIC!  =  Nad  +  IW  +  <'(),.  The  hydro- 
chloric acid  is  neutralized  and  the  resultant  sodium  chloride  is 
removed  by  the  kidneys  while  the  carbon  dioxide  is  given  off  by 
the  lungs. 


NATURE  OF  DIABETIC  ACIDOSIS  161 

"Henderson1  calls  the  carbonates  of  the  blood  the  first  line  of 
defense.  Thus,  dyspnea,  more  properly  hyperpnea  or  increased 
pulmonary  ventilation,  under  abnormal  circumstances,  is  an  agent 
of  the  greatest  value  in  ridding  the  body  of  carbon  dioxide  and  thus 
keeping  the  reaction  within  normal  limits.  It  may  also  be  remarked 
that  hyperpnea  is  the  best  of  all  the  evidences  of  acidosis  to  be 
obtained  by  physical  examination  alone.  It  may  almost  be  said 
that  hyperpnea  means  acidosis. 

"  If  the  bicarbonates  of  the  plasma  were  the  only  method  of 
defense  of  the  body  the  organism  would  succumb  to  acidosis  as 
soon  as  the  bicarbonate  was  depleted  by  the  excretion  of  neutral 
salts  through  the  kidneys;  every  molecule  of  an  acid  would  rob  the 
body  of  a  molecule  of  bicarbonate.  The  second  mechanism  here 
comes  into  play  and  is  that  by  which  acids  may  be  removed,  leaving 
behind  part  of  the  base  with  which  they  have  been  combined,  this 
base  being  available  for  further  neutralization.  The  elimination 
is  by  the  way  of  the  kidneys.  These  have  the  capacity  to  excrete 
an  acid  urine  from  a  nearly  neutral  blood.  They  remove  acid  phos- 
phate and  save  base  with  each  molecule  of  acid  phosphate  that  they 
excrete.  Thus,  although  alkali  is  eliminated  in  the  urine,  it  is  much 
less  than  would  be  the  case  without  this  specialized-kidney  activity, 
and  can  readily  be  replaced  under  normal  circumstances  by  the 
alkali  of  the  food.  For  instance,  with  the  introduction  of  a  foreign 
acid— Xa2IIPO4  +  HC1  =  XaCl  +  XaII2PO4— the  hydrochloric  acid 
is  neutralized,  the  sodium  chloride  and  acid  sodium  phosphate  are 
excreted  by  the  kidneys  or  the  following  reaction  may  take  place 
-NasPHO*  +  HoO  +  CO2  =  XaII,PO4  +  NaHCO3.  By  this  method 
the  sodium  bicarbonate  reserve  of  the  body  is  renewed. 

"Henderson  and  Palmer  showed  the  magnitude  of  alkali  sparing 
very  prettily  by  titrating  with  alkali  the  acid  urine  back  to  the 
normal  reaction  of  the  blood.  The  alkali  spared  was  found  in  normal 
subjects  to  vary  in  terms  of  tenth-normal  alkali,  between  20(3  and 
800  c.c.  This  is  equivalent  to  saying  that  the  kidneys  eliminate 
from  200  to  800  c.c.  of  tenth-normal  acid  in  twenty-four  hours." 

(c)  Safeguards  of  the  Body  against  Acidosis. — Two  of  the  chief 
safeguards  of  the  body  against  acidosis  have  been  already  discussed, 
namely,  the  removal  of  carbonic  acid  by  the  lungs  without  depleting 
the  body's  store  of  alkali,  and  second,  the  reaction  between  a 
molecule  of  disodium  phosphate  and  a  molecule  of  acid  by  which 
the  sodium  bicarbonate  of  the  blood  is  conserved  and  yet  large 
quantities  of  acid  are  eliminated. 

The  glycogen  storage  in  the  liver  and  muscles  of  the  body  was 
considered  Xature's  chief  safeguard  against  acidosis  until  it  was 
shown,  as  tile  result  of  the  fasting  treatment  of  diabetes  inaugurated 

1  Henderson:    Am.  Jour.  Phys.,  190S,  xxi,  p.  427. 
11 


1(>2     FACTORS   IX   TREAT  ME  XT   OF   DIAKKTEX   MELUTCX 

by  Allen,  that  acidosis  usually  disappeared  in  these  individuals 
while  fasting.  It  is  hard  to  give  up  this  hypothesis  even  now, 
although  the  low  respiratory  quotient  of  these  patients  indicates  very 
little  carbohydrate  being  burned.  The  anomaly  becomes  greater 
when  it  is  considered  that  ;i  healthy  individual,  fasting  or  on  a  non- 
protein  dic-t,  develops  an  acidosis,  whereas  a  severe  diabetic  treated 
in  exactly  the  same  manner  loses  an  acidosis.  There  is  surely 
something  here  which  is  not  understood.1  It  would  appear  that  the 
diabetic  individual  is  able  to  manufacture  and  utili/e  some  sub- 
stance which,  in  its  combustion,  is  able  to  prevent  acidosis,  but 
yet  a  material  which  is  not  available  to  the  normal  individual,  and 
the  fact  that  as  the  aeidosis  decreases  the  respiratory  quotient 
rises  above  that  to  be  expected  upon  a  fat-protein  diet  is  favorable 
to  this  view.  These  considerations  show  the  importance  of  a 
determination  of  the  amount  of  carbohydrate  stored  in  the  diabetic 
organism.  In  considering  carbohydrate  storage  one  must  not 
neglect  to  include  the  large  amount  of  carbohydrate  which  is 
available  when  the  protein  molecule  breaks  up.  This  is  we'll 
illustrated  by  Case  No.  51;!,  Avith  onset  at  thirty-three  years,  who 
finally  succumbed  to  multiple  carbuncles,  septicemia,  and  diabetic 
coma,  three  years  later.2  During  the  last  four  days  of  life,  while 
fasting,  due  chiefly  to  his  inability  to  retain  food,  he  excreted  142.4 
grains  nitrogen.  This  would  represent  the  metabolism  of  SOU3 
grains  protein  and  the  setting  free  of  5.'54  grams  carbohydrate.  As  a 
matter  of  fact  the  dextrose-nitrogen  ratio  in  this  case  was  ;!.():!, 
showing  Nature's  fruitless  struggle  to  conquer  an  acidosis. 

Another  safeguard  against  acidosis  exists  in  the  large  amount  of 
alkali  stored  in  the  body.  Not  only  are  sodium  and  potassium 
present  in  considerable  quantities,  but  in  emergency  the  organism 
can  fall  back  upon  the  calcium  and  magnesium  of  the  bones. 
Cerhardt  and  Schlesinger1  originally  pointed  out  that  these  alkalis 
met,  an  attack  of  severe  acidosis  by  changing  their  path  of  excretion 
from  the  bowels  to  the  kidneys,  in  this  manner  removing  /i-oxy- 
butyric  acid.  In  a  study  of  the  urine;  of  Case  No.  4  during  coma,5 
Mc(  'rudden  found  for  me  unusually  large  quantities  of  calcium  and 
magnesium  excreted  in  the  urine.  Whereas  40  per  cent,  of  the 
magnesium  is  normally  excreted  in  the  t'eces,  in  Case  No.  4  during 
three  days  0.55  gram  was  found  in  the  urine,  but  only  0.15  in  the 
feces.  Similarly,  2.0.'!  grams  calcium  appeared  in  the  urine,  but 
0.75  gram  were  eliminated  by  the  intestinal  tract. 

1  See  AYoodyatt's  paper  read  before  the  Association  of  American  Physicians,  Mill), 
for  a  fresh  discu-sion  of  this  point.  .lour.  Am.  Mod.  Assn.,  l'.)l('),  Ixvi,  p.  HMO. 

-  See  p.  :r>:i 

•'<  s.">  1  «ram>  if  1-^ram  nitrogen  is  taken  to  represent  (i  grains  hoili/  protein — the 
more  correct  factor.  See  Benedict.  Carnegie  Pnli.  L'IKi,  p.  -100. 

'('.eihardi  and  Schloin^er:    Arch.  f.  Path.  11.  I'har.,  ISO!),  xlii,  p.   100. 
r',Io-lin:    Jour.  Med.  Research,  1'JOl,  i,  p.  :i()(i. 


NATURE  OF  DIABETIC  ACIDOK1S  1(>3 

Another  important,  and  indeed  a  most  remarkable  means  of 
defense  of  the  body  against  aeidosis  lies  in  its  power  to  excrete 
nitrogen  in  the  form  of  ammonia  instead  of  urea,  as  in  health. 
How  efficiently  Nature  works  is  evident  when  it  is  realized  that  1 
gram  of  ammonia  (NII;!  molecular  weight  17)  can  neutralize  five 
times  as  much  /3-oxybutyric  acid  as  1  gram  sodium  bicarbonate 
(XaIICO3  molecular  weight  <S4). 

"Still  another  protection  against  aeidosis  is  afforded  by  the 
proteins.  The  part  they  play  is  probably  not  as  great  as  that  of 
the  bicarbonates  or  phosphates.  It  depends  upon  their  amphoteric 
character.  Proteins  can  combine  with  appreciable  amounts  of 
either  acids  or  alkalis  without  undergoing  marked  changes  in  reac- 
tion. The  details  of  this  action  are  obscure,  but  the  influence  of 
protein  is  undoubted"  (Ilowland). 

(r/)  Aeidosis  Varies  According  to  the  Rapidity  of  Onset,  the  Age 
of  the  Patient  and  the  Condition  of  the  Kidneys. — It  has  often  been 
my  experience  to  see  fatal  coma  result  from  an  aeidosis  of  only 
moderate  degree  which  has  come  on  suddenly,  whereas  in  another 
individual  the  gradual  development  of  an  aeidosis  of  equal  severity 
has  been  borne  with  comparative  ease.  The  cases  of  coma  which 
are  relieved  by  prompt  treatment  are  generally  cases  in  which  a 
moderate  aeidosis  has  suddenly  appeared  as  the  result  of  some 
extraneous  cause. 

Children  and  adults  under  the  age  of  forty  years  withstand 
aeidosis  better  than  older  patients.  Goodall  and  Joslin1  found 
that  the  former  group  of  patients  tolerated  an  aeidosis  estimated 
in  terms  of  ammonia  of  4  or  5  grams  far  better  than  the  latter 
group  bore  an  aeidosis  represented  by  2.5  to  4  grams  ammonia. 
This  was  due,  in  our  opinion,  to  the  greater  vulnerability  of  the 
kidneys  of  older  people.  The  sound  kidneys  of  young  people 
readily  excreted  the  acid,  but  the  kidneys  of  the  elderly  or  diseased 
kidneys  in  any  individual  excreted  the  acid  with  difficulty,  and  a 
trifling  aeidosis  in  such  individuals  might  lead  to  serious  results. 
Tileston  and  Comfort  have  shown  from  investigations  upon  the  non- 
protein  nitrogen  in  the  blood  of  children  and  the  phenolphthalein 
test  that  the  secreting  capacity  of  the  child's  kidney  was  better  than 
that  of  an  adult.'-  Harmful  aeidosis  occurred  in  Case  No.  347, 
first  seen  in  1910,  male,  aged  fifty-one  years,  with  an  onset  sixteen 
months  before,  lie  was  discharged  from  the  hospital  sugar-free 
with  no  aeidosis,  but  the  urine  contained  a  little  albumin,  the  blood- 
pressure  was  175  mm.  mercury,  and  the  heart  extended  half-way  to 
the  anterior  axillary  line,  the  liver  three  fingerbreadths  below  the 
costal  margin  and  the  spleen  palpable.  At  discharge  I  did  not 
sufficiently  emphasize  to  his  physician  this  existing  kidney  trouble. 

1  Goodall  and  Joslin:    Boston  Mod.  and  Sur<r.  .lour.,  I'.MIS,  rlviii,  p.  046. 

2  Tileston  and  Comfort:    Am.  Jour.  Dis.  Child.,  1915,  x,  p.  278. 


104     /•'.•!  (TO  A'.S   I\    TI{EATME\T  OF   DIABETES   MELLlTL'fi 

The  patient,  as  is  often  the  case  with  diabetic  adults  on  diet,  upon 
his  own  initiative  still  further  restricted  the  quantity  of  carbohydrate 
which  he  was  allowed,  an  acidosis  developed,  and  with  it  marked 
albuminuria ;  both  rapidly  increased.  ( 'ardiac  weakness  ensued  and 
coma  gradually  developed  from  which  he  was  unable  to  recover. 

(c)  Culmination  of  Acidosis  in  Coma.-  The  effects  of  extreme 
acidosis  artificially  induced  in  normal  individuals  are  very  suggestive 
of  the  beginning  symptoms  of  coma  in  diabetic  patients.  Such 
(  xperiments  show  the  relation  of  acidosis  to  coma  quite,  as  effectually 
as  the  coma  which  "Walter1  originally  produced  in  animals  by  the 
injection  of  hydrochloric  acid.  It  is  impossible  to  state  how  much 
p-oxybutyric  acid  and  its  allied  bodies  are  necessary  to  produce 
coma.  There  are  probably  wide  variations  depending  on  the  stor- 
age of  carbohydrate,  protein,  alkalis  and  water,  as  well  as  upon  the 
ability  of  the  cardiorcnal  system  to  excrete  the  acid  when  formed. 
In  some  cases,  like  Case  No.  4,  large  quantities  of  acid  are  excreted, 
but  undoubtedly  more  often  large  quantities  are  retained. 

Diabetic  coma  usually  creeps  on  so  insidiously  that  unless  one 
is  in  the  habit  of  treating  diabetic  patients  it  may  be  overlooked 
until  all  at  once  its  spectacular  features  anxiety  and  exaggerated 
respiration  with  the  absence  of  cyanosis — stare  one  in  the  face. 
The  onset,  can  usually  be  attributed  to  some  change  by  which'  carbo- 
hydrates are  removed  from  the  diet,  and  fats  increased,  by  design 
or  accident.  In  one  instance  marked  nervous  excitement  on  the 
part,  of  the  patient  appeared  to  play  a  great,  role,  but  I  think  the 
accompanying  refusal  of  food  and  later  vomiting  made  this  case 
also  one  of  sudden  carbohydrate  restriction.  Typical  examples  of 
the  onset  of  coma  are  Cases  Nos.  )!10,  2~i'2,  L'20,  N.'Ki  and  7l21).  ( 'ase 
No.  o  10,  who  had  had  diabetes  twenty-one  years,  showed  a  moderate 
acidosis  over  a  period  of  months,  then  sailed  for  Kurope,  became 
seasick,  "was  unable  to  retain  food,  and  in  three  days  died  of  coma. 
Case  No.  '2~)'2,  while  upon  a  rather  more  restricted  diet  than  usual, 
nine  years  after  onset,  underwent  exceptional  exertion  and  coma 
developed.  Case  No.  L'20,  having  lived  comfortably  for  years 
despite  ;i  severe  acidosis,  had  a  gastro-intestinal  attack,  was  much 
debilitated,  the  diet  was  disarranged,  and  coma  followed.  Case 
No.  Sod  after  suffering  wit  h  diabetes  for  only  three  months,  travelled 
several  thousand  miles,  and  during  the  latter  part  of  the  journey 
acquired  diphtheria;  on  my  first  visit  (eight  hours  before  death) 
this  was  discovered,  and  along  with  it  diabetic  coma.  Case  No. 
7l'!l,  a  severe  diabetic,  three  months  after  her  last  visit  to  me,  with- 
out my  knowledge,  was  taken  to  a  dent isl  's  office,  given  ether  by  her 
physician,  and  all  her  teeth  extracted.  This  was  on  .Monday: 
she  was  taken  home,  became  unconscious  Wednesday  and  died  on 
Frida  v. 

Walter:    Arch.  I.  oxp.   Path,  u.  I'h.-irm.,   Is77,  vii,  p.  MS. 


SECTION  III. 

THE  EXAMINATION  OF  THE  URINE,  BLOOD  AND 
RESPIRATION  IN  DIABETES. 


A.     THE  EXAMINATION  OF  THE  URINE. 

1.  The  Desirability  of  Routine  Examinations  of  Urine  of  All 
New  Patients,  and  of  All  Old  Patients  Annually. — An  early  diag- 
nosis in  diabetes  is  as  important  as  in  tnbereulosis.  The  disease 
usually  begins  insidiously  and  its  prompt  detection  depends  upon  the 
routine  examination  of  the  urine  of  all  patients  rather  than  upon  the 
examination  of  the  urines  of  patients  who  present  symptoms  of  the 
disease.  It  is  inexcusable  to  neglect  to  examine  the  urine  of  any 
case  coming  for  treatment.  The  wealthy  parents  of  Case  No.  ]  123 
built  a  hospital  for  their  community,  but  two  doctors  failed  to 
examine  the  urine  of  their  child  and  diabetes  was  diagnosed  by  a 
nurse.  I  attach  so  much  significance  to  this  point  that  I  believe 
if  the  physician  is  unable  to  secure  the  urine  from  the  patient  he 
should  record  this  fact  for  his  own  self-protection.  Practitioners  in 
all  branches  of  medicine  should  examine  the  urines  of  their  patients 
or  demand  a  recent  urinary  report.  1  except  no  specialist,  whether 
he  be  surgeon,  ophthalmologist,  otologist,  laryngologist,  gynecolo- 
gist, neurologist,  orthopedist  or  dentist.  All  would  be  incompar- 
ably rewarded  if  they  made  gratuitous  examinations  of  the  urine 
for  all  patients  coming  to  them.  The  expense  would  be  trifling, 
the  good  done  would  be  enormous.  Furthermore,  such  thorough- 
ness would  redound  to  the  credit  of  those  who  adopted  it.  General 
practitioners  should  teach  their  patients,  as  a  matter  of  routine, 
to  have  their  own  urines  and  those  in  their  families  examined  each 
birthday.  This  is  not  fantastic.  It  is  simply  a  part  of  the  move- 
ment to  have  each  member  of  the  community  undergo  a  physical 
examination  each  year. 

(n)  Inexpensive  Urinary  Examinations. — Examination  of  the  urine 
should  cost  the  patient  little.  Formerly  I  deprecated  the  routine 
examinations  made  in  drug  stores,  but  now  I  welcome  them  because 
such  examinations  are  so  inexpensive.  The  mystery  attached  to 
a  urinary  analysis  should  be  abolished.  For  years  I  have  had  my 

(165) 


100        I'ltIXE,   HLOOD  AM)   HKM'IHATION  IN  DIABETES 

laboratory  reports  recorded  on  slips,  gummed,  and  in  blocks, 
OJ  by  1  (';  inches,  so  as  not  to  impress  the  patients  with  a\ve.  When 
I  see  two  or  even  four  full  pages  covered  with  a  single  urinary  report 
and  padded  printed  matter,  yet  showing  on  the  face  of  it  that 
modern  analytical  methods  were  not  employed,  I  blush  for  the 
profession.  When  a  urinary  report  was  shown  me  for  which  a 
boy's  father  had  paid  ten  dollars,  it  was  with  considerable  satisfac- 
tion that  1  taught  the  child  to  do  the  qualitative  Benedict  test 
for  sugar,  the  materials  for  which  can  be  purchased  at  less  than 
one  cent. 

(h]  The  Importance  of  a  Physician's  Laboratory. — On  the  other 
hand,  a  physician's  laboratory  and  his  urinary  examinations  are 
often  poor.  It  is  not  the  rule  for  a  physician  to  quantitate  the 
sugar  in  the  urine  even  by  the  fermentation  test.  The  comparison 
between  the  outlay  which  the  surgeon  is  willing  to  make  for  the 
conduct  of  his  practice  with  that  of  the  physician  is  most  unfavor- 
able to  the  latter.  The  surgeon  almost  invariably  takes  pride  in 
his  equipment,  purchasing  new  apparatus  and  discarding  old  with 
a  lavish  hand.  The  physician  seldom  expends  the  fraction  of  this 
outlay  in  the  development  of  a  laboratory.  This  should  be  entirely 
different.  The  physician  should  take  as  much  pride  in  a  well- 
equipped  and  neat  laboratory  as  the  surgeon  in  his  instrument  case. 
When  one  sees  the  condition  of  the  laboratory  or  lack  of  laboratory 
of  the  ordinary  practitioner,  little  wonder  is  aroused  that  his  diabetic 
patients  are  sometimes  poorly  treated  or  that  his  patients  have 
little  respect  for  his  laboratory  reports. 

Most  eases  of  diabetes  go  on  for  months,  many  for  years,  without 
being  diagnosed.  For  example,  in  my  series,  out  of  11  Mo  cases 
which  are  available  for  statistics  in  this  regard,  at  the  most  12X0  cases, 
or  2o  per  cent.,  showed  an  acute  onset  of  the  disease.  This  shows 
the  necessity  for  frequent  urinary  examinations. 

((•')  Causes  which  Lead  to  the  Examination  of  the  Urine  of  Diabetic 
Patients.  (1  )  Llj'c  Insurance  Examinations.—  Life  insurance  exami- 
nations led  to  the  detection  of  sugar  in  the  urine  of  10  per  cent, 
of  the  7M2  male  cases  of  my  series.  The  percentage  of  cases  in  each 
hundred  detected  by  insurance  steadily  increased  from  the  first 
to  the  sixth  hundred,  but  thereafter  has  remained  about  constant 
at  S  per  cent.  The  outcome  of  these  cases  deserves  consideration, 
for  it  is  presumable  that  these1  individuals  came  under  earlier  and 
better  treatment  than  the  routine  eases  of  diabetes,  and  this  fact 
undoubtedly  is  one  explanation  of  the  more  favorable  course1  of 
diabetes  in  males.  It  is  not  strange,  therefore,  to  record  that  of 
these  70  cases,  1  is  untraeed,  Oo  or  S7  per  cent,  are  alive.  I  know 
it  will  be  claimed  that  these  were  mild  cases,  and  for  that  reason  1 
give  facts.  (See  Table  90.) 


THE  EXAMINATION  OF   THE   URINE 


107 


TABLE  90. — DIABKTES  DISCOVERED  AT  EXAMINATION  FOR  LIFE   INSURANCE. 


Case    NO. 

Age 

at 
onset. 

Per 

cent, 
over 
weight 

Sugtir. 
highest 
per 

cent, 
found. 

Duration 
to  Death 
or  Dec.  1, 
1916, 
years. 

Case  No. 

Age 

at 
onset. 

Per 
cent. 

over 

weight. 

Sugar, 
highest 
per 
cent, 
found. 

Duration 
to   Death 
or  Dec.  1, 
1916, 

years. 

20   .       . 

29 

14 

1.3 

19.0 

751    .      . 

53 

54 

0.8 

10.3 

177   .       . 

39 

29 

2.0 

10.0 

700  .       . 

45 

Trace 

3  .  0 

179   .       . 

54 

IS 

4.2 

12.9 

779  .       . 

38 

7.0 

7.5*2 

1SS   .       . 

58 

9 

o.s 

11.8 

783   .       . 

24 

3 

1.2 

2.3 

231    .       . 

51 

44 

3.2 

10.4 

784  .       . 

45 

0.4 

1.6*3 

270   .       . 

29 

—  8 

3.2 

7.9 

819   .       . 

34 

0 

Trace 

1.9 

329   .       . 

58 

42 

7  .7 

18.0 

828  .       . 

37 

1 

2.0 

2.5 

331   .      . 

34 

22 

0.6 

0.4 

829   .       . 

51 

61 

2.0 

3.0 

353   . 

53 

4.0 

2.5*i 

835  .      . 

31 

-6 

1.9 

9  .  5 

372  .       . 

4,s 

4.0 

3.5*'-' 

837  .       . 

36 

17 

Untraeed 

379  .      . 

42 

3.2 

3.0 

844  .       . 

22 

16 

4.8 

3  .  0 

392  .      . 

40 

17 

0.8 

11.0 

S47   . 

24 

13 

2.0 

1.8 

409  .      . 

48 

5  .  0 

11.2 

850  .       . 

45 

0 

0.2 

4.2 

411    .       . 

30 

Trace 

13.7 

804   .       . 

38 

i 

0.2 

1  .8 

435  .      . 

39 

0 

Trace 

15.3 

888   . 

48 

7.0 

4G7  .       . 

54 

5 

7  2 

9.2 

898   .       . 

49 

1.4 

i  .  3 

40S  .      . 

20 

52 

5'.4 

10.8 

921   . 

59 

1.2 

1.3 

474  .      . 

58 

7 

0.4 

4  4*5 

920  .       . 

29 

1.3 

509  .      . 

40 

Trace 

4.8 

941   .       . 

47 

18 

Trace 

9  .  0 

510  .      . 

40 

0.1 

4.4 

948  .       . 

36 

8 

Trace 

1.1 

520  .       . 

56 

5  .  0 

10.8*- 

977   .       . 

32 

15 

8  .  3 

9.7 

544  .      . 

37 

—  5 

2  .  0 

3.0 

1034  .      . 

35 

2.0 

13.0 

572  .      . 

27 

0.2 

3.9 

1055  .      . 

41 

0.6 

18.0 

5S3   .      . 

34 

-17 

Trace 

4.4 

1050  .      . 

50 

2 

0.8 

10.0 

5s7  . 

51 

.14 

5  .  0 

14.8 

1000 

27 

0 

0.6 

16.0 

590   .       . 

50 

0.8 

4  .  3 

1077   .      . 

33 

0 

Trace 

0.5 

009   .       . 

20 

13 

Trace 

3.7 

1091   .      . 

40 

Trace 

12.0 

01S  . 

51 

Trace 

4.5 

1090  .      . 

30 

-10 

Trace 

5  .  3 

030   .       . 

54 

50 

0.0 

5  .  5*2 

1104  .      . 

36 

11 

0.2 

0.6 

03S  .       . 

49 

3 

0.9 

0.3 

1124  .      . 

10 

1 

4.0 

2.9 

043   .       . 

33 

31 

1  .() 

11  .0 

1131   .      . 

20 

0.2 

0.5 

057  . 

50 

4  .  3 

1142  .       . 

40 

30 

Trace 

1.5 

003   .      . 

27 

o 

0.4 

3.9 

1149  .      . 

21 

1 

0  .  3 

OSS   .        . 

40 

7.0 

7.0*4 

1105  .       . 

51 

50 

5  .  6 

2.0 

093   .      . 

44 

0.0 

25  .()*- 

1107   .      . 

33 

28 

2.0 

18.5 

099   .       . 

31 

2.6 

3.1 

1109  .      . 

59 

14 

0.0 

0.1 

720  .       . 

87 

—  7 

0.2 

2  .  0 

1205  .      . 

45 

2   2 

21  .0* 

735  .      . 

41 

18 

Trace 

2.0 

1223  .      . 

28 

34 

Trace 

1.9 

(2)  Routine  Examinations, — The  sugar  was  found  in  the  urine  and 
the  diagnosis  was  made  simply  as  a  result  of  a  physician's  routine 
urinary  examination  in  124  cases,  10  per  cent,  of  my  series.  The 
outcome  of  the  diabetes  in  these  individuals  shows  SO  per  cent, 
living.  I  give  my  figures  in  detail.  It  will  be  noted  that  the  table 
also  shows  the  period  which  had  existed,  as  disclosed  by  subsequent 
inquiry,  between  the  symptomatological  onset  of  the  disease  and 
the  urinarv  test.  See  Table  91. 


*  Signifies  fatal. 
3  Pneumonia. 


1  Tuberculosis. 
4  Cancer  of  kidney. 


TABLE  91. — DIABETES  DISCOVERED  BY  ROUTINE  URINARY  EXAMINATION. 


.1 
Case  Xo. 

01 

Estimated 

time  between 
LKO          onset  and 
it       demonstration 
set  .       of  tituiar  in 
urine, 
months. 

Duration 
to   Death 
or  Dec.   1,        Case  N 
1910, 

years. 

Estimated 
time  between 
ARC          onset  and 
o.    j      at       dernonstratioi 
onset  .       of  stifjar  in 
urine, 
months. 

Duration 
to   Death 
or  Dec.  1, 

11)1(1, 
years- 

173    .      . 

15                   0 

9.2            ~S0    . 

3S               1  1 

3.2 

341  .     . 

12                  0 

0.0            SOU    . 

10                  S 

2.S 

303  .     . 

14                  1 

5.3*'        S02    . 

43                 0 

s.o*' 

3sf>  .     . 

19                   1 

7.2            NO')    . 

4S               12 

10.0 

3S7    .      . 

U                  0 

l.(J*i        ,S23    . 

4S                  1 

G.7*» 

391  .     . 

50                 0 

fill  raced      *30    . 

45                 0 

17.0 

•to:}  .     . 

55                 0 

0.1*-        S5S    . 

05                0 

1.5 

105    .       . 

.'()                 0 

0.0            SOI    . 

5  1                 4 

2  2*9 

•JOG    .       . 

10               11 

0.2           803    . 

32               30 

4.0 

•129    .       . 

-.0             o 

0.4           807    . 

52               20 

3.7 

•103  .     . 

20                 0 

10.0           <S70    . 

35                0 

12.7 

•ISO    .       . 

51                 0 

4.8*'-       SSI    . 

05               12 

2.3 

507    .      . 

10                 11 

5.4           SS3    . 

54              24 

2.0 

".IS    .        . 

27                 0 

4.9           SS5    . 

53                6 

2.0 

319   .      . 

17                11 

2.2*i       ssG    . 

2S              1  2 

1.8*9 

321     .         . 

59              "21 

7.3           918    . 

47                0 

3  .  2 

523     .        . 

54                3 

2.5           928    . 

43                0 

9.1 

527    . 

}5     ,            0 

5.0*5       929    . 

09 

1  .2*'° 

531   .     . 

10     '            1 

4.4          031    . 

03                 0 

9.0 

55S     . 

54                0 

0.5          943    . 

50                 0 

1.3 

505     . 

59                 0 

9.0           944    . 

40                0 

11.0 

573    .      . 

1C)                 2 

13.S           947    . 

49               1  2 

5.4 

574    .      . 

33                2 

3.9           949    . 

7                1 

5  .7 

"),S4    .      . 

53                0 

4.0          959    . 

5S                5 

4.0 

5S9    .      . 

00     '          10 

4.8          902    . 

54           -1211 

10.0 

'Mi    .      . 

0                 1 

O.S*1        909    . 

42                0 

5.9 

598    .       . 

59                2 

3.S          971    . 

.53                3 

2.5 

599    .      . 

)2                 1 

3.s*"       973    . 

45           -12 

0.0 

G2s   .      . 

10              47 

0.3*:!       970    . 

.    '     50             1  day 

0.9 

040    .      . 

10                0 

5.3          9S1    . 

2S                 0 

1.3 

042    .      . 

14                0 

I'ntraced      984    . 

17                  1 

l.G*i 

04!)    .       . 

17                0 

12.0           9S9    . 

20                  1 

1.2 

050    .       . 

34               13 

l.S*i        991    . 

04                5 

1.3 

000    .       . 

27               12 

4.8          992    . 

42                4 

4.3 

001    .       . 

32               1  2 

4.2           993    . 

.    ,     42           -12 

10.0 

005    .       . 

i()                2 

1  .2*5       994    . 

15                 1 

2.7 

009    .       . 

15                9 

l.S*i      1000    . 

1 

1  .7 

074    .       . 

j<>                 1 

3.1          1003    . 

4  1                 3 

1  .  1 

07S    .       . 

10                  1 

5.4          1013    . 

43           -12 

2.0 

GS1     .        . 

31                 5 

3.3         1010    . 

30               12 

1.9 

GS9    .       . 

13               12 

9.2          1019    . 

00              12 

1  .0*1° 

091    .       . 

53                 1 

5.0         1031    . 

45              30 

13.0 

092    .       . 

32               1  0 

3.5          1035    . 

8                 1 

0.7 

097    .       . 

19                  1 

S.S          103S    . 

37               30 

3.0 

70.'5    .       . 

3,'i                 2 

7.3          1012    . 

59                  1 

0.  1*3 

704    .       . 

10                 0 

14.5          1015    . 

55                 4 

1  .0 

705    .       . 

32                1  2 

S.5         1017    . 

00               12  + 

7.0 

700    .       . 

22                 4 

1  .5         1002    . 

53            -12 

15.0 

712    .       . 

-'9                    1 

2.s         1071    . 

14                 1 

1  .0 

713    .       . 

37  •               0 

5.0         1072    . 

03           -12 

S.O 

710    .       . 

11                 3 

1.9          107s 

.   '     4s                1 

2  .  9 

7->k> 

10                 5 

3.  1          1095    . 

47                 1 

3  .  3 

7'*5 

32                 0 

1  .  2*4     :109S    . 

.         40               24 

7.0 

72s 

511                  0 

3.5         1100    . 

•',0                    1 

0.9 

730    .       . 

37                 0 

13.3        14133    . 

50                3 

0.4 

731    .       . 

7                10 

l.S*i        137    . 

.14                2 

0.3 

74*    .       . 

11                  0 

3.3            115    . 

00                 1 

7  7 

719    .       . 

11                  0 

19.0*="      157    . 

5S              30  ± 

0.0± 

750    .       . 

3 

0.2*          15s    . 

.   ,     5s 

19.0 

759    .      . 

10                 0 

12.7*1        102 

.   j       5               4 

1.4 

700    .       . 

4                  1 

1.3*1        211     . 

70           -12 

4.0 

77S    -      .    j     . 

33                  1 

0.1            225    . 

43               12 

1  .0 

*  Signifies  fatal.     '  C'oma. 

4  Hemiplegia.         fj  Pneumonia. 

8  Carbuncle.  9  Tuberculosis. 


2  C.antzrene. 

6  Cancer  stomach. 

10  Cardiac. 


3  Enlarged  prostate. 
7  Abdominal  infection. 
11  Under  1  year. 


THE  EXAMINATION  OF   THE   URINE  169 

(3)  Other  Causes. — The  other  causes  which  led  to  the  examination 
of  urine  were  those  usually  recorded  in  the  symptomatology  of 
diabetes,  namely,  polyuria,  polydipsia,  loss  of  weight,  weakness, 
pruritus,  pains  in  back  or  legs,  but  almost  never  polyphagia. 

2.  The  Mixed  Twenty-four-hour  Quantity  of  Urine  should  be 
Examined. — The  mixed  twenty-four-hour  quantity  of  urine  should 
be  examined.     Many  cases  of  diabetes  show  sugar  in  the  urine  at 
only  one  period  of  the  day.     The  urine  which  1  have  found  most 
apt  to  contain  sugar  is  that  voided  after  the  noonday  meal.     This 
might  be  explained  by  the  hearty  meal,  the  absence  of  exercise 
following  it,  and  the  fact  that  this  is  the  business  period  of  the  day, 
hence  the  patient  is  under  excitement.     Case  No.  30  showed  0.3 
per  cent,  of  sugar  in  the  urine  on  March  20,  1902.     Gradually  the 
specimens  of  urine  voided  became  sugar-free,  but  that  after  lunch 
began  to  be  constantly  sugar-free  November  7,   190S.     The  last 
urinary  examination  of  this  case  was  December  17,  1914,  at  which 
time  the  patient  reported  he  was  taking  100  to  125  grams  carbo- 
hydrate, and  the  urinary  nitrogen  amounted  to  13.2  grams.     The 
urine  least  apt  to  contain  sugar  is  that  voided  on  rising.     This 
is  not  strange,  for  the  urine  is  voided  several  hours  after  the  last 
meal   upon   retiring  and  the   subsequent  urine  is  a  fasting  urine. 
No  patient  with  or  without  diabetes  is  to  be  considered  sugar-free 
unless  the  twenty-four-hour  specimen  of  urine  is  proved  free  from 
sugar.     Case  No.  978  showed  no  sugar  in  a  single  specimen,  but  in  a 
twenty-four-hour  amount  there  was  0.0  per  cent.   In  illustration 
of  the  above  I  would  mention  Case  No.  473,  who  showed  7  per 
cent,   of  sugar  in  January,    1912,   but  the  urine  was  pronounced 
sugar-free  in  the  preceding  November  and  December,   although 
the  patient  was  losing  weight  rapidly  in  those  months.     Inves- 
tigation disclosed  that  only  the  morning  specimen  of  urine  had 
been  examined  on  either  occasion.     Case  No.   4S8  was  accepted 
by  an  insurance  company  who  depended  upon  the  examination  of  a 
specimen  of  urine  voided  before  dinner.     He  was  refused  shortly 
after   by  a   second   insurance  company,   who  found  sugar  in  the 
specimen  voided  after  dinner. 

3.  The  Volume  of  Urine  in  Twenty-four  Hours. — The  quantity 
of  urine  frequently  coincides  with  the  quantity  of  sugar  eliminated 
and  von  Noorden1  gives  the  following  table: 

TABLE  92. — VOLUME  OF  URINE,  SPECIFIC  GRAVITY  AND  PERCENTAGE  OF 
SUGAR  COMPARED. 


Specific  Sugar 

c.c.                                                               gravity.  percentage. 

1500-  2,500 1025-1030 2-3 

2500-  4,000 1030-1030 3-5 

4000-  0.000 1032-1040 4-7 

6000-10,000 1036-1040 6-9 

1  Von  Xoordeii:    Loc.  cit.,  p.  125. 


170        1'ItIXE,   BLOOD   AM)   ItESI'l  If  AT/OX   IN   DIABETES 


But  the  volume  of  urine  may  give  little  index  of  the  seventy  of 
diabetes.  ( 'ases  of  diabetes  deeipiens  are  most  common.  ( 'ase  Xo. 
S  at  onset  of  treatment  showed  1030  c.c.  of  urine  with  5  per  cent, 
of  sugar,  and  twelve  years  later  112")  e.e.  of  urine  with  2.4  per 
cent,  of  sugar.  Case  Xo.  340  showed  o.S  per  cent,  of  sugar  in  iS(')f) 
c.c.  of  urine,  ('ase  Xo.  3~)l>  showed  o.S  per  cent,  of  sugar  in  103") 
c.c.  of  urine.  In  other  words,  the  twenty-four-hour  quantity  of 
urine  may  be  normal  and  yet  contain  a  large  amount  of  sugar.  A 
patient's  report  that  he  is  voiding  a  normal  quantity  of  urine, 
therefore,  is  no  excuse  for  the  neglect  of  a  urinary  examination. 
However,  it  is  unusual  for  the  urine  to  be  normal  in  quantity  unless 
the  patient  is  sugar-free. 

There  arc  other  exceptions  to  Table  92.  Severe  cases  of  diabetes 
passing  through  a  period  of  restricted  diet  show  a  steady  and 
daily  diminution  in  the  quantity  of  urine  consistent  with  the 
restriction  of  carbohydrate,  provided  acidosis  is  absent.  On  the 
other  hand,  if  acidosis  appears,  it  is  occasionally  found  that  the 
volume  of  urine  fails  to  decrease  and  may  rise.  The  quantity  of 
urine  may  be  quite  independent  of  the  amount  of  sugar  which  is 
excreted.  The  emaciated  Case  Xo.  1190  was  sugar-free  yet  voided 
over  3000  e.e.  urine  for  days  and  the  only  cause  found  was  increased 
nitrogenous  metabolism  despite  a  low  protein  intake.  (See  p.  379.) 
Case  Xo.  9S2  was  also  sugar-five,  but  his  increased  volume  was 
explained  by  the  abnormal  intake  of  salt.  (See  p.  284.) 

TABI.I:  9o. — CIIAHT  OF  CASK  Xo.  347. 


Dat 


Urii 


1010 

.!' 

ilv  11  : 

1000     SI.  + 

0 

11 

12o() 

0      ll.S 

Hi 

1  .">(  H  ) 

(I 

is 

1000 

0 

L'O 

1  .">(  K  ) 

0 

21 

i:>7.~>  '• 

0 

The  volume  of  urine  of  Case  Xo.  3-1*  changed  little  as  the  sugar 
decreased,  despite  renal  involvement.  Onset  March  17,  1909  (acute), 
first  seen  -Inly  11,  1910.  Blood-pressure  at  that  time  170;  the  arteries 


hospital  upon  the  patient's  own  initiative 


THE  EXAMINATION  OF   THE   URINE  171 

showed  moderate  sclerosis.  The  heart  extended  well  out  toward  the 
anterior  axillary  line,  the  liver  was  three  fingerbreadths  below  the 
eostal  margin  and  the  spleen  was  palpable  at  the  eostal  margin. 
The  patient  became  sugar-free  quite  promptly  without  the  de- 
velopment of  acidosis,  as  will  be  seen  from  Table  93.  Soon 
after  leaving  the  hospital  he  omitted  alkali  and  restricted  his  diet 
still  further,  and  on  August  3,  1910,  cardiac  failure,  accompanied 
by  an  increased  quantity  of  albumin  and  acidosis  appeared,  and  he 
died  on  August  19,  1910.  This  case  illustrates  the  necessity  of 
care  in  the  restriction  of  the  diet  of  patients  with  impaired  renal 
functions. 

A  nearly  normal  quantity  of  urine,  even  with  a  large  percentage 
of  sugar,  when  patients  first  come  for  treatment  is  usually  a  favor- 
able prognostic  sign.  On  the  other  hand,  a  marked  polyuria  is  by 
no  means  always  an  unfavorable  omen.  Case  Xo.  5X5  shows  this. 
Onset  of  diabetes  at  forty-nine  years  of  age,  first  seen  at  fifty-two 
years  and  eleven  months  on  February  13,  1913.  Table  94  shows 
that  a  large  volume  of  urine  with  a  high  percentage  of  sugar  in  a 
woman  with  diabetes  of  three  years'  duration  need  not  necessarily 
be  regarded  unfavorably. 

TABLE  94. — CHART  or  CASE  Xo.  585.     VOLUME  OF  URINE  LARGE,  YET 
COURSE  OF  CASE  FAVORABLE. 


Date, 

Volume,    ':     Specific 
c.c.               gravity. 

Diacetic       Nitrogen, 

acid.               gnis. 

Ammonia.        Sujiar, 
total               total 
Kins.                finis. 

1913 

Feb.   21       ... 

ftfoO            1044 

0 

500 

Mar.    9       ... 

2250            1030 

0 

1  20 

23       .      .      . 

2000            1033 

0 

OS 

July     1       ... 

2115            1040 

0 

140 

AUK.    4     ... 

2000            1025 

- 

11     ... 

1500            1020 

0 

13 

IS       ... 

IGsO            1027 

0 

2 

Nov.    4      ... 

2000            1030 

SI.  +              18 

1.30               27 

1914 

Summer 

Successfully  shipwrecked  off    the  const 

of  Ireland. 

1916 

Jan.    17       ... 

1000            1020 

0                  19 

()' 

1017 

Jan.      2       ... 

2000            1029 

0                  14 

50 

The  greatest  volume  of  urine  in  twenty-four  hours  in  comparison 
to  the  weight  of  the  patient  was  voided  by  Case  Xo.  1151,  who 
developed  diabetes  at  the  age  of  three  years  and  came  under  my 
care  at  the  age  of  ten  years  weighing  IS. (>  kilos  in  October,  191C>. 
During  the  first  fifteen  hours  at  the  hospital  the  volume  of  urine 


1  Carbohydrate  in  diet,  40  grams 


172        1'ItIXK,    BLOOD   AXD   REXI'I  h'ATIOX   IX   DIABETES 


THE  EXAMINATION  OF   THE   URINE  173 

was  7200  +  c.c.,  and  for  the  following  twenty-four  hours  7000  c.c. 
The  course  of  the  ease  is  shown  in  Fig.  2.  It  will  be  noted  that 
during  the  first  sixteen  hours  the  little  boy  was  in  the  hospital  he 
voided  7200  e.c.  of  urine,  or  39  per  cent,  of  his  weight.  If  one 
should  calculate  on  the  same  basis  the  total  twenty-four-hour 
quantity  of  urine,  it  would  amount  to  10,SOO  c.c.,  or  58  per  cent, 
of  the  body  weight. 

The  volume  of  urine  should  be  expressed  in  cubic  centimeters. 
This  enables  the  percentage  of  the  twenty-four-hour  amount  of 
sugar  to  be  most  readily  calculated.  An  ounce  of  urine  is  actually 
29. ()  c.c.,  but  I  usually  reckon  it  in  clinical  work  as  30  c.c.,  for  the 
errors  in  collection  of  urine  more  than  offset  the  trifling  error  in 
the  equivalent.  One  quart  of  urine  is  equivalent  to  940  c.c.  From 
experience  with  patients,  I  believe  accurate  enough  figures  are 
obtainable,  except  for  scientific  experiments,  if  we  consider  a  quart 
of  urine  1000  c.c.,  and  I  am  content  with  this  rule  because  the  error 
comes  in  reporting  too  little  rather  than  too  much  urine.  Naturally, 
such  methods  are  absolutely  barred  when  accurate  work  is  being 
done.  At  the  New  England  Deaconess  Hospital  bottles  graduated 
to  50  cubic  centimeters  are  exclusively  employed.  These  obviate  the 
necessity  of  measuring  the  urine.  1  strongly  advise  the  use  of  the 
metric  system,  both  in  recording  the  urine  and  in  computing  the 
quantity  of  sugar,  and,  indeed,  for  the  diet  as  well.  Most  patients 
are  glad  to  adopt  it.  The  avoirdupois  system  involves  too  much 
labor.  I  recall  few,  if  any,  instances  of  a  physician  who  was  accus- 
tomed to  record  the  volume  of  the  urine  and  quantity  of  sugar  by 
the  avoidupois  system  who  knew  the  total  amount  of  sugar  voided 
by  his  patient  in  twenty-four  hours.  How  could  such  a  physician 
estimate  the  quantity  of  carbohydrate  in  the  diet  in  grains  to  the 
ounce? 

4.  The  Specific  Gravity. — The  specific  gravity  of  the  urine  in 
diabetes  is  usually  high,  but  Case  Xo.  3X  showed  sugar  in  the  urine 
when  the  specific  gravity  was  1007.  A  low  specific  gravity,  there- 
fore, is  no  more  excuse  for  neglecting  to  examine  the  urine  for 
sugar  than  is  a  normal  quantity  of  urine.  The  specific  gravity  of 
the  urine  has  taken  on  increased  significance  since  it  has  been  shown 
that  variations  in  the  specific  gravity  during  the  day  indicate  very 
satisfactorily  the  functional  power  of  the  kidney.  Perhaps  no  test 
of  renal  function  is  of  so  great  value  for  the  general  practitioner  or 
so  simply  performed. 

The  fixation  of  specific  gravity  is  well  illustrated  in  Table  95. 
The  patient,  Case  No.  10X0,  was  a  man,  aged  sixty-nine  years,  with 
piostatic  obstruction,  and  the  following  test  was  made  90  days 
subsequent  to  the  removal  of  the  prostate  gland  by  Dr.  A.  L. 
Chute.  It  will  be  seen  that  during  the  whole  twenty-four  hours 


174        r/i'/A'/',',    HL(H)I)   AM)   RKM'IRATIOX   IN   DIAHKTKH 

tlie  specific  gravity  varied  from  lOOSto  1012.  Along  with  the  figures 
for  the1  specific  gravity  are  included  the>se>  for  salt  and  nitrogen,  and 
it  will  be  encouraging  te>  the  practising  physician  te>  observe  that  the1 
information  disclosed  by  the-  spe-e-ifie'  gravity  was  ejuite1  as  valuable 
as  that  obtained  by  these-  other  analyses,  which  required  so  much 
time.  The  constancy  in  the  percentage  of  salt  and  nitrogen  in 
the  urine,  however,  is  most  striking.  For  further  details  concern- 
ing this  case  see  page  211. 

TAIU.K  '.to. — Tin;   FIXATION  OF  Si-iccinc  (!KAVITV.     CASK   No.    10X0,   p.    17)). 


Time.                               Volume, 
c.c. 
Oct.  :;i,  ntiti. 

Salt.                           Nit,- 

Specific 

.KO... 

^r:ivity. 

Per  cent        Grams.        IVr  cent,. 

Crams. 

X  to    10  A.M  '          I-'50 

1012           ().4.-{      ;     0.71           0..',2 

O.G7 

10  to  12      "         ....           1:50 

loos         o.r>:;        2.0          o.:-!2 

t.3 

12  to     2  I-..M  200 

1012           0.4              1.2             O.ol 

1  .  1 

2  to    4     "        ....          I.").', 

1010           0.4             ().!«           0.57 

0.9 

4  to    (i     "        ....          210 

1010           0.42           1.4              0.4.S 

1.1(5 

0  to    X      "         ....          270 

1012           0.47           1  .4             0.47 

1.2fi 

x  to    x  A.M  1  1-">0 

1012           0./17           4.1              0.47 

5.4 

Totals          ....       2.~>7.~> 

12.77 

11.70 

5.  Tests  for  Glucose. — (Dextrose,  Cell^Oe).— It  is  the  ])resence 
or  absence  of  glucose  in  the  urine1  which  is  important  rather 
than  the  percentage  of  sugar,  though  a  knowledge  of  the  latter 
is  essential  for  careful  work.  The  quantity  of  sugar  in  the 
urine  should  be  recorded  in  per  cent,  and  in  grains  for  the  twenty- 
four  hours.  The  clinic  upon  diabetes  given  by  Friedrich  vonMiiller 
at  the  Boston  ( 'ity  Hospital,  in  which  he  illustrated  the  total  amount 
of  sugar  voided  by  the  patient  by  exhibiting  an  equivalent  amount 
of  cane-sugar,  was  most  instructive.  It  is  not  the  percentage  of 
sugar  which  is  important  in  the  urines  of  diabetic  patients,  it  is  the 
"total  quantity  of  sugar  eliminated  in  the  twenty-four  hours. 

(a)  Qualitative  Tests.  Many  of  the1  qualitative  tests  for 
glucose;  are1  excellent,  and  nearly  all  have1  the1  advantage  that 
although  sugar  is  pre-se-nt  in  the1  urine'  of  normal  individuals,  they 
fail  to  demonstrate  its  presence  unle-ss  the1  sugar  exists  in  a  greater 
than  normal  amount.  I  ntil  recently  I  have  found  Fehling's  te-st 
to  be1  most  generally  useful.  Lately,  1  have  used  it  less  because1  the 
Benedict  test  reejuircs  a  single-  solution,  keeps  indefinitely  and  the1 
re-action  offers  less  chance1  for  e-rror.  I'nfortunately  it  is  a  little-  too 
dedicate-  and  repeatedly  traces  of  sugar  in  supposedly  normal  urines 
have  been  reported.  It  will  be-  interesting  to  note-  whether  it  is 
adopted  as  a  routine1  te-st  by  life  insurance  companies. 


THE  EXAMINATION  OF   THE   URINE  175 

(1) '  Fehlin r/'.v  Test.— In  performing  the  test,  3  to  5  c.c.  of  equal 
quantities  of  the  eopper  solution  and  the  alkaline  solution  are 
mixed  in  a  test-tube  and  thoroughly  boiled.  If  no  reduetion  takes 
place  one-half  as  much  urine  as  the  reagent  employed  is  then  added 
and  the  whole  boiled  vigorously  again.  A  yelhnv  or  red  precipi- 
tate indicates  the  presence  of  sugar;  a  greenish  precipitate  may 
or  may  not  indicate  sugar.  Occasionally  substances  in  the  urine 
other  than  sugar  reduce  the  copper  upon  prolonged  boiling,  but 
this  is  so  exceptional  that  I  consider  it  far  safer  to  boil  the  solu- 
tion a  second  time,  and  when  in  doubt,  to  repeat  the  test  without 
boiling. 

(2)  Benedicts  Test.1 — Five  cubic  centimeters,  a  trifle  over  one 
teaspoonful,  of  the  Benedict  solution,  are  placed  in  a  test-tube  and 
8  to  10  drops  (not  more)  of  the  urine  to  be  examined  are  added. 
The  mixture  is  then  heated  to  vigorous  boiling,  kept  at  this  tem- 
perature for  three  minutes,  and  allowed  to  cool  spontaneously. 
In  the  presence  of  glucose  the  entire  body  of  the  solution  will  be 
filled  with  a  precipitate,  which  may  be  greenish,  yellow  or  red  in 
tinge,  according  to  whether  the  amount  of  sugar  is  slight  or  con- 
siderable. If  the  quantity  of  glucose  be  low  (under  0.3  per  cent.), 
the  precipitate  forms  only  on  cooling.  If  no  sugar  be  present,  the 
solution  either  remains  perfectly  clear,  or  shows  a  faint  turbidity 
that  is  blue  in  color,  and  consists  of  precipitated  unites.  The  chief 
points  to  be  remembered  in  the  use  of  the  reagent  are  (1)  the 
addition  of  a  small  quantity  of  urine  (S  to  10  drops)  to  5  c.c. 
of.  the  reagent,  this  being  desired  not  because  larger  amounts  of 
normal  urine  would  cause  reduction  of  the  reagent,  but  because 
more  delicate  results  are  obtained  by  this  procedure;  (2)  vigor- 
ous boiling  of  the  solution  after  addition  of  the  urine,  and  then 
allowing  the  mixture  to  cool  spontaneously,  and  (3)  if  sugar  be 
present  the  solution  (either  before  or  after  cooling)  will  be  filled 
from  top  to  bottom  with  a  precipitate,  so  that  the  mixture  becomes 
opaque. 

Benedict  (personal  communication)  states  that  the  test  as  per- 
formed above  will  detect  glucose  in  as  low  concentration  as  0.01  to 
0.02  per  cent,  provided  the  urine  is  of  low  dilution. 

The  formula  and  directions  for  preparing  the  Benedict  solution 
follow;  they  should  be  strictly  adhered  to  in  preparing  the  solution: 


Copper  sulphate  (pure  crystallized) 17.3 

Sodium  or  potassium  citrate 173.0 

Sodium  carbonate   (crystallized)    (one-half  the  weight   of  the 

anhydrous  salt  may  be  used) 200.0 

Distilled  water  to  make 1000.0 

1  Benedict:    Jour.  Am.  Med.  Assn.,  1011,  Ivii,  p.  1193. 


170       URINE,   BLOOD  AX  I)  RESPIRATION  IN  DIABETES 

The  citrate  and  carbonate  are  dissolved  together  (with  the  aid 
of  heat)  in  about  TOO  e.c.  of  water.  The  mixture  is  then  poured 
(through  a  filter),  if  necessary,  into  a  larger  beaker  or  casserole. 
The  copper  sulphate  (which  should  be  dissolved  separately  in 
about  100  c.c.  of  water)  is  then  poured  slowly  into  the  first  solution, 
with  constant  stirring.  The  mixture  is  then  cooled  and  diluted 
to  one  liter.  This  solution  keeps  indefinitely. 

Folin1  comments  instructively  upon  the  various  qualitative 
tests:  "The  sensitiveness  of  the  various  alkaline  copper  solu- 
tions employed  in  testing  for  sugar  depends  probably  most  of  all 
upon  how  little  cuprous  oxide  they  are  capable  of  holding  in  solu- 
tion. The  merit  of  Stanley  R.  Benedict's  qualitative  test  for 
sugar  is  due  in  large  part  to  its  solvent  effects  on  cuprous  oxide, 
although  it  possesses  the  additional  advantage  of  being  but  slightly 
reduced  by  creatinin.  The  creatinin  disturbs  not  only  by  its 
reducing  power,  but  also  by  its  property  of  holding  relatively  con- 
siderable traces  of  cuprous  oxide  in  solution." 

(o)  Folin'x  Test. — A  qualitative  reduction  test  for  sugar  in  normal 
human  urine.-  "This  test  depends  (1)  on  the  use  of  an  uncom- 
monly sensitive  alkaline  copper  solution,  and  (2)  on  the  fact  that 
in  the  presence  of  copper  alkaline  pierate,  solutions  are  not  reduced 
by  sugar.  The  importance  of  the  last-named  consideration  lies 
in  the  fact  that  it  permits  the  removal  of  the  creatinin  and  other 
substances  with  picric  acid  before  applying  the  reduction  test. 

"The  reagent  is  made  up  in  two  solutions: 

"A.  5  grams  of  crystallized  copper  sulphate  are  dissolved  in 
100  c.c.  of  hot  water  and  to  the  cooled  solution  are  added  GO  to 
70  c.c.  of  pure  glycerin. 

"  B.  125  grams  of  anhydrous  potassium  carbonate  are  dissolved 
in  400  c.c.  of  water. 

"One  part  of  the  glycerin-copper  solution  (A)  is  mixed  with  two 
parts  of  potassium  carbonate  solution  (B).  Only  small  portions 
should  be  mixed  at  a  time,  as  the  reagent  (after  mixing)  does  not 
keep  but  undergoes  gradual  reduction. 

"The  test  is  made  as  follows:  To  about  10  c.c.  of  urine  in  a 
test-tube  or  small  flask  add  about  2  grains  of  picric  acid  and  about 
2  grams  of  good  quality  bone-black  (Kahlbaum's  or  Merck's 
blood  charcoal),  shake  for  five  minutes,  and  filter. 

"Concentrated  urines,  which  give  the  most  trouble  in  testing 
for  sugar,  contain  from  )>  to  5  ing.  creatinin  per  cubic  centimeter. 
By  the  above  procedure  the  creatinin  content  is  reduced  to  prac- 
tically nothing-  at  the  most  a  few  hnndredths  milligrams  per 
cubic  centimeter  being  left  in  the  filtrate.  Bone-black  has  very 

1  Folin:    .lour.  Hi 

2  Folin:  Ibid, 


THE  EXAMINATION  OF   THE   URINE  177 

strong  absorbing  properties  for  the  picrates  of  creatinin.  By 
allowing  the  urine  and  picric  acid  to  stand  for  a  longer  time  (half 
an  hour  or  overnight)  the  addition  of  bone-black  may  be  omitted 
if  desired.  The  filtrate  in  that  case  will  contain  about  0.1  mg. 
per  cubic  centimeter,  a  quantity  too  small  to  interfere  with  the 
test  for  sugar. 

"Add  1  or  2  c.c.  of  the  creatinin-free  filtrate  to  about  10  c.c.  of 
the  freshly  mixed  sugar  reagent  in  a  large  test-tube  (together  with 
a  pebble  or  two  to  prevent  bumping)  and  boil  with  constant  shaking 
(the  shaking  is  desirable  to  avoid  bumping  and  is  necessary  to 
prevent  superheating  and  consequent  reduction  of  the  reagent  on 
the  sides  of  the  test-tube)  for  one  and  a  half  minutes.  If  the  sugar 
present  is  considerable  (above  the  normal  variations),  a  typical 
reduction  is  obtained.  If  the  trace  of  sugar  is  smaller,  but  still 
rather  large,  the  whole  solution  will  become  turbid  as  in  Benedict's 
test.  If  no  such  turbidity  is  produced  and  the  boiling  mixture 
remains  clear,  transfer  it  at  once  (i,  e.,  while  still  very  hot)  to  a 
centrifuge  tube  and  centrifuge  for  one  or  two  minutes.  Typical 
red  cuprous  oxide  such  as  obtained  with  pure  sugar  solutions  will 
be  found  in  the  bottom  of  the  centrifuge  tube  below  the  green 
crystalline  potassium  picrate  which  usually  forms  as  the  liquid 
cools. 

"Some  copper  reagents  made  as  described  above  give  a  slight 
cuprous  oxide  sediment  when  boiled  alone,  i.  e,.  without  any  added 
sugar  or  urine.  When  that  is  the  case  the  reagent  must  be  boiled 
and  centrifuged  once  before  using  it  for  the  test." 

A  method  for  the  determination  of  small  amounts  of  sugar  in 
the  urine  has  recently  been  devised  by  V.  C.  Myers.1 

(1))  Multiple  Qualitative  Tests. — The  performance  of  a  quali- 
tative test  for  sugar  in  the  urine  requires  scarcely  three  minutes, 
but  when  there  are  ten  to  twenty  urines  to  be  examined  the  amount 
of  time  consumed  is  considerable.  Time  thus  spent  is  wasted. 
With  this  in  mind  my  assistant,  B.  H.  Ragle,2  undertook  to  examine 
simultaneously  several  urines  qualitatively  for  sugar  by  utilizing 
a  water-bath  with  perforated  top.  Later  he  found  that  Prof. 
Victor  Myers  and  Dr.  Morris  Fine  had  already  described  a  bath 
filled  with  saturated  solution  of  calcium  chloride  for  a  similar 
purpose.3  (These  writers  also  describe  various  practical  methods 
for  routine  urinary  examinations  in  hositals.4)  It  would  appear 
that  the  water-bath  filled  with  water  is  equally  as  good.  A 

1  Myers:  Loc.  fit.,  p.  17. 

2  Ragle:  Boston  Med.  and  Surg.  Jour.,  1915,  clxiii,  p.  746. 

3  Myers  and   Fine:      Essentials   of   Pathological    Chemistry,    reprinted   from   the 
Post-Graduate,  1912-1913,  New  York,  p.  127. 

4  Myers  and  Fine:    New  York  Med.  Jour.,  1913,  xcvii,  p.  1126. 

12 


178       1'RIXK,   BLOOD  A XI)  RESPIRATION  IN  DIABETES 

water-bath,  with  a  top  perforated  for  test-tubes,  either  round  01 
rectangular  in  type  is  suitable. 

If  Bent-diet's  solution  is  used  the  directions  are  as  follows:  The 
water-bath,  filled  with  )>  cm.  water,  is  placed  over  a  large  flame. 
While  the  water  is  coining  to  a  boil  about  5  c.c.  of  the  reagent  are 
introduced  into  the  same  number  of  test-tubes  as  there  are  urines 
to  be  examined.  A  very  handy  way  is  to  have  the  tubes  in  a  rack, 
and  the  solution  can  be  siphoned  into  them  from  a  bottle.  Eight 
drops  of  urine  are  now  put  into  each  test-tube  and  the  tubes  immedi- 
ately transferred  to  the  actively  boiling  water-bath  and  left  for  five 
minutes.  Within  thirty  seconds  to  one  minute  urines  containing 
().")  per  cent,  or  more  of  sugar  will  have  reduced  the  copper,  and  in 
five  minutes  any  specimen  with  a  pathological  trace  of  dextrose 
will  give  a  positive  reaction. 

The  method  is  just  as  applicable  to  Eehling's  qualitative  test. 
After  the  preliminary  proof  that  the  Fehling's  solution  is  not  reduced 
by  boiling  the  tests  are  carried  out  in  the  ordinary  manner  and 
placed  in  the  boiling  bath  for  five  minutes. 

The  advantages  of  this  method  are  that  multiple  qualitative  tests 
for  sugar  may  be  made  simultaneously  with  little  labor,  bumping  is 
avoided,  and  test-tubes  are  less  apt  to  be  broken.  1  cannot  too 
strongly  recommend  this  simple  procedure. 

Dr.  John  A.  Peterson,  of  llingham,  tells  me  that  he  lias  used  this 
method  for  individual  sugar  tests,  and  I  have  adopted  it  as  a  routine 
method  for  patients  to  use  at  home.  They  call  it  the  "teapot 
method,"  because  a  little  teapot,  reserved  for  the  purpose,  is  so 
convenient  for  the  test  and  the  kitchen  stove  is  far  safer  than  to 
heat  a  test-tube  over  an  alcohol  lamp. 

(c)  Quantitative  Tests.-  All  quantitative  tests  for  glucose  in 
the  urine  are  as  unsatisfactory  as  the  qualitative  tests  are  satis- 
factory. It  is  one  of  the  chief  advantages  of  modern  treatment 
that  the  need  for  these  tests  is  nearly  abolished.  It  will  be  one 
of  the  disadvantages  of  modern  treatment  if  we  introduce  a  mul- 
tiplicity of  new  tests  in  diabetes.  The  simplification  of  the  treat- 
ment of  diabetes  means  everything  to  the  practitioner  and  patient. 
The  best  quantitative  test  for  sugar  for  physicians  who  do  not 
devote  unusual  attention  to  diabetes  is  the  fermentation  test. 

(1)  Fermcnfntion  7V.v/.-  To  100  c.c.  of  urine  of  known  specific 
gravity,  one-fourth  of  a  fresh  yeast  cake,  thoroughly  broken  up,  is 
added  and  the  whole  is  set  away  at  a  temperature  of  S.V3  to  5).")°  V. 
Twenty-four  hours  later  the  urine  is  tested  with  Fehling's  or 
Benedict's  solutions.  If  a  reduction  is  obtained  it  is  set  aside  for 
further  fermentation.  Complete  fermentation  having  been  proved 
the  specific  gravity  is  taken  after  the  urine  has  acquired  its  original 
(room)  temperature,  The  difference  in  specific  gravity  multiplied 


THE  EXAMINATION  OF   THE   URIXE  179 

by  0.23  gives  the  percentage.  In  the  performance  of  the  fermenta- 
tion test  for  sugar  a  few  crystals  of  tartaric  acid  should  be  added 
whenever  the  urine  is  alkaline.  If  the  temperature  of  the  urine 
(room)  is  76°  F.  when  the  specific  gravity  is  taken  at  the  begin- 
ning and  end  of  the  test  the  result  will  be  still  more  accurate. 
The  physician  who  expends  two  cents  of  his  own  money  for  a  yeast 
cake  to  perform  this  simple  quantitative  test  for  sugar  usually  knows 
far  more  about  the  treatment  of  diabetes  than  his  brother  practi- 
tioner who  expends  $10  of  his  patient's  money  fora  laboratory  report. 
The  test  is  most  valuable  in  determining  the  presence  or  absence 
of  traces  of  sugar.  At  the  end  of  twenty-four  hours,  if  the  filtered 
urine  which  previously  showed  a  doubtful  test  for  sugar  with  Feh- 
ling's  or  Benedict's  solutions  shows  no  reduction  upon  repetition 
of  the  test,  it  can  be  assumed  that  a  fermentable  substance,  pre- 
sumably glucose,  was  present.  If  further  doubt  exists,  the  use 
of  the  polariscope  and  the  phenylhydrazin  tests  will  help  to  settle 
the  question. 

(2)  Polar iscopi/. — The  determination  of  the  percentage  of  sugar  by 
means  of  the  polariscope  is  the  most  convenient  of  all  quantita- 
tive tests  for  glucose.     The  test  is  easily  performed  during   the 
patient's  visit   and   the   result   so   obtained    can    be    immediately 
utilized  for  treatment.     The  quantity  of  urine  required  for  the  test 
is  small  and  quantitative  solutions  are  not  needed.     It  is  not  usually 
recognized  that  in  the  vast  majority  of  cases  simple  filtration  suf- 
ficiently clarifies  the  urine  to  allow  of  its  examination.     This  saves  a 
few  minutes'  time  in  one  examination,  but  the  aggregate  of  many 
hours  in  the  course  of  a  year.     Should  it  be  necessary  to  decolorize 
the   urine,    use   infusorial   earth.     Magnus-Levy   has   pointed   out 
that  the  employment  of  lead  acetate  introduces  an  error.     Unfor- 
tunately   in    the   presence   of    /3-oxybutyric    acid    the    polariscope 
gives  too   low  a   reading,   for    /3-oxybutyric   acid   is    levorotatory, 
whereas  glucose  (dextrose)  is  dextrorotatory.     This  error  may  be 
considerable,   even   amounting  to   as   much  as  57  grams  sugar  in 
twenty-four  hours  in  Case  Xo.  235. 

To  obviate  this  the  levorotatory  power  of  the  urine  can  be  deter- 
mined after  fermentation,  and  this  fraction  of  a  percentage  added 
to  the  percentage  of  sugar  obtained  before  fermentation.  But 
this  calculation  is  not  very  satisfactory  and,  beskles,  requires  a 
long  time.  Whenever,  therefore,  /3-oxybutyric  acid  is  present 
and  accurate  knowledge  of  the  percentage  of  sugar  in  the  urine  is 
desired  the  Benedict  test  should  be  performed.  In  general  the 
promptness  with  which  the  determinations  with  the  polariscope 
can  be  made  discount  this  error  in  clinical  work. 

(3)  Fehling's    Test. — I    have    little   faith    in   this   test,  because 
it  is    so    difficult    to    determine    the    end-point.     Various  modi- 


180       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

fieations  of  the  tost  have  appeared,  and  at  one  time  and 
another  I  have  employed  some  of  them  only  later  to  discard  them. 
At  present  I  use  instead  the  quantitative  test  described  by  Stanley 
R.  Benedict.  Fehling's  quantitative  method,  however,  is  as  fol- 
lows: Dilute  10  e.c.  of  Fehling's  solution  (5  c.c.  copper  sulphate 
and  5  c.c.  alkaline  tartrates)  with  40  c.c.  of  water  and  boil  in  a 
flask  to  test  the  solution.  Add  slowly,  by  means  of  a  burette,  the 
urine  diluted  with  water  1  :  10.  After  each  addition  boil  briskly. 
When  the  point  is  reached  at  which  the  blue  color  wholly  disappears 
the  copper  is  reduced.  Ten  c.c.  of  Fehling's  solution  are  reduced 
by  0.05  gram  of  glucose,  which  is,  therefore,  the  amount  of  glucose 
in  the  urine  used.  The  percentage  of  glucose  equals  5,  divided  by 
the  number  of  cubic  centimeters  of  undiluted  urine.  To  get 
accurate  results  with  this  method,  the  dilution  of  the  urine  or  the 
amount  of  water  added  to  the  Fehling's  solution  in  the  flask  should 
be  such  that  about  100  c.c.  of  fluid  are  present  at  the  completion 
of  the  test. 

(4)  Benedict's  Test} — "Like  Fehling's  quantitative  process,  the 
method  is  based  on  the  fact  that  in  alkaline  solution  a  given  quantity 
of  glucose  reduces  a  definite  amount  of  copper,  thus  decolorizing  a 
certain  amount  of  copper  solution.  The  copper  is,  however,  pre- 
cipitated as  cuprous  sulphocyanate,  a  snow-white  compound,  which 
is  an  aid  to  accurate  observation  of  the  disappearance  of  the  last 
trace  of  color.  The  solution  for  quantitative  work,  which  keeps 
indefinitely,  has  the  following  composition: 

"  Pure  crystallized  copper  sulphate,  18  grams. 

"Crystallized  sodium  carbonate,  200  grams  (or  100  grams  of  the 
anhydrous  salt). 

"Sodium  or  potassium  citrate,  200  grains. 

"Potassium  sulphocyanide,  125  grams. 

"  Five  per  cent,  potassium  ferrocyanide  solution,  5  c.c. 

"Distilled  water  to  make  a  total  volume  of  1000  c.c. 

"With  the  aid  of  heat  dissolve  the  carbonate,  citrate,  and  sulpho- 
cyanide in  enough  water  to  make  about  800  c.c.  of  the  mixture 
and  filter  if  necessary.  Dissolve  the  copper  sulphate  separately 
in  about  100  c.c.  of  water  and  pour  the  solution  into  the  other 
liquid,  with  constant  stirring.  Add  the  ferrocyanide  solution, 
cool  and  dilute  to  exactly  one  liter.  Of  the  various  constituents 
the  copper  salt  only  need  be  weighed  with  exactness.  Twenty-five 
c.c.  of  the  reagent  an'  reduced  by  50  ing.  (0.050  grain)  of 
glucose." 

The  procedure  for  the  estimation  is  as  follows:  "The  urine, 
10  c.c.  of  which  should  be  diluted  with  water  to  100  c.c.  (unless 

'Benedict,  S.  !{.:  The  Quantitative  Estimation  of  Glucose  in  the  Urine,  Jour. 
Am.  Med.  Assn.,  Chicago,  I'.Ul,  Ivii,  p.  1193. 


THE  EXAMINATION  OF   THE   URINE 


181 


the  sugar  content  is  believed  to  be  low),  is  poured  into  a  50  c.c. 
burette  up  to  the  zero  mark.  Twenty-five  c.c.  of  the  reagent  are 
measured  with  a  pipette  into  a  porcelain  evaporating  dish  (10 
to  15  cm.  in  diameter),  10  to  20  grams  of  crystallized  sodium  car- 
bonate (or  one-half  the  weight  of 
the  anhydrous  salt)  are  added 
together  with  a  small  quantity  of 
powdered  pumice  stone  or  talcum, 
and  the  mixture  heated  to  boiling 
over  a  free  flame  until  the  car- 
bonate has  entirely  dissolved. 
The  diluted  urine  is  now  run  in 
from  the  burette,  rather  rapidly, 
until  a  chalk-white  precipitate 
forms  and  the  blue  color  of  the 
mixture  begins  to  lessen  percep- 
tibly, after  which  the  solution  from 
the  burette  must  be  run  in,  a  few 
drops  at  a  time,  until  the  disap- 
pearance of  the  last  trace  of  blue 
color  which  marks  the  end-point. 
The  solution  must  be  kept  vigor- 
ously boiling  throughout  the  entire 
titration." 

If  the  mixture  becomes  too 
concentrated  during  the  process, 
water  may  be  added  from  time 
to  time  to  replace  the  volume  lost 
by  evaporation;  however,  too 
much  emphasis  cannot  be  placed 
upon  the  fact  that  the  solution 
should  never  be  diluted  before  or 
during  the  process  to  more  than 
the  original  25  c.c.  Moreover,  it 
will  be  found  that  in  titrating 
concentrated  urines,  or  urines  with 
small  amounts  of  sugar,  a  muddy 
brown  or  greenish  color  appears 
and  obscures  the  end-point  en- 
tirely. Should  this  be  the  case 
the  addition  of  about  10  grams  of 
calcium  carbonate  does  away  with 
this  difficulty.  The  calculation  of  the  percentage  of  sugar  in  the 
original  sample  of  urine  is  very  simple.  The  25  c.c.  of  copper  solu- 
tion are  reduced  by  exactly  0.050  gram  of  glucose.  Therefore  the 


FIG.  3.—  Apparatus  required  for  a 
simplified  quantitative  Benedict  test 
(p.  182). 


182        ('HIM-:,    BLOOD   AM)   REHPI  RATIOS   IX   DIAKETES 

volume  of  diluted  urine  dra\\'ii  out  of  the  burette  to  eil'eet  the 
reduction  contains  ~>()  nig.  of  sugar. 

\Yhen  the  urine  is  diluted  1  To  10,  as  in  the  usual  titration  of 
diabetic  urines,  the  formula  for  calculating  the  percentage  of  sugar 
is  the  following: 

X   1000  --  pei'centa^'    in    the   original  sani])le,  wherein  ,r  is 

tlu>  number  of  <:ubic  centimeters  of  the  diluted  urine  required  to 
reduce  2o  c.c.  of  the  copper  solution. 

"In  the  use  of  this  method  chloroform  must  not  be  present  dur- 
ing the  titration.  if  used  as  a  preservative  in  the  urine  it  may  be 
removed  by  boiling  a  sample  for  a  few  minute's,  and  then  diluting 
to  the  original  volume." 

My  laboratory  assistant,  Miss  Kvelyn  Warren,  suggested  the  use 
of  white  enamelware  dishes  instead  of  porcelain  in  the  performance 
of  the  Benedict  quantitative  test.  These  serve  the  purpose  admir- 
ably and  the  saving  in  expense  is  very  considerable.  J  recommend 
their  adoption  in  the  laboratories  of  large  hospitals  quite  as  strongly 
as  for  smaller  laboratories  of  physicians.  The  equipment  of  a 
diabetic  nurse  includes  this  apparatus  (Fig.  o)  and  the  rules  given 
for  the  performance  of  the  test  are  as  follows: 

Jii'LKs  FOR  NntsKs  ix  PERFORMING  THE  SIMPLIFIED 
QUANTITATIVE  BEXEDKT  TEST. 

Articles   Required, 

Ten  c.c.  graduated  pipette;  small  white  enamelware  dish,  ',]  inches 
across,  2  inches  deep;  sodium  carbonate;  talcum. 

The  test  can  be  performed  by  the  aid  of  a  kitchen  gas  burner. 
If  the  gas  burner  is  not  a  small  one  and  so  flares  up  around  the  edges 
of  the  dish,  put  an  asbestos  plate  over  it  or  simply  an  iron  cover. 


1.  Place  .">  c.c.  of  the  quantitative  Benedict  solution  in  the  dish. 

2.  Add  less  than  one-fourth  teaspoonful  of  sodium  carbonate. 
IS.   Add  one-half  as  much  talcum. 

4.   Add  about   10  c.c.  water. 

.").  Dilute  1  part  urine  with  0  parts  of  water  unless  the  quantity 
of  sugar  is  low.  (A  low  percentage  of  sugar  is  shown  by  the  qualita- 
tive Benedict  test  turning  green  instead  of  yellow,  \\ith  small 
quantities  of  sugar  it  is  unnecessary  to  dilute  the  urine.) 

(').  Bring  the  contents  of  the  dish  to  a  boil,  maintain  in  this  con- 
dition and  then  add,  drop  by  drop,  the  urine  from  the  graduated 
pipette  until  the  blue  color  has  entirely  disappeared.  I  poll  the 


THE  EX  AM  IX  AT  I  OX  OF   THE   URINE  1S3 

first  trial  too  much  may  be  added,  and  therefore,  having  noted 
the  approximate  quantity  of  urine  required  to  reach  the  end-point, 
invariably  repeat  the  test  as  a  control. 

Calculation. 

Five  c.c.  of  the  Benedict  quantitative  copper  solution  are  reduced 
by  0.01  gram  glucose.  Consequently,  the  quantity  of  undiluted 
urine  required  to  reduce  the  o  c.c.  Benedict  solution  contains  0.01 
gram  glucose. 

-  X  100  =  per  cent.  x  =  c.c.  of  undiluted  urine. 

.r 

Example.  —  Fifteen  hundred  c.c.  urine  in  twenty-four  hours. 
Five  c.c.  used  to  reduce  (decolorize)  Benedict  solution. 

C      l  x  100  =  0.2  per  cent. 
o 

1")00  X  0.002  (0.2  per  cent.)   =  3  grams  sugar  i  i  twenty-four  hours. 

Example.  —  If  the  urine  had  been  diluted  with  !)  parts  water,  in 
other  words,  10  times,  the  calculation  would  be: 

o  c.c  dilute  1  urine.  =  O.o  c.c.  actual  urine. 
(]-  X  100  =  2  per  cent. 


1500  X  0.02  (2  per  cent.)  =  30  grams  sugar  in  twenty-four  hours. 

(5)  Peter's  Test.  —  A  most  accurate  method  for  the  quantitative 
determination  of  glucose  in  the  urine  has  been  devised  by  Dr.  A.  AY. 
Peters,  and  has  been  used  with  satisfaction  at  the  Nutrition  Labora- 
tory. It  is  unfortunately  more  complicated  than  the  practitioner 
would  care  to  adopt.1 

(i.  Tests  for  Other  Sugars.  —  Other  sugars  than  grape-sugar  are 
occasionally  found  in  the  urine.  It  is  rare  that  they  cause  confu- 
sion. It  is  not  quite  so  easy  to  detect  or  to  exclude  them,  as  would 
appear  from  the  description  of  the  tests  by  which  they  are  said  to 
be  identified.  Of  these  various  sugars  lactose  is  the  one  most 
commonly  encountered. 

(a)  Lactose  (('^HoaOn).  —  i.actose  in  the  urine  may  give  rise  to 
confusion  in  the  performance  of  Fchling's  or  Benedict's  tests. 
Fortunately,  the  conditions  in  which  it  is  liable  to  occur,  pregnancy 
and  the  lactation  period,  are  usually  known  to  the  physician,  and 
it  is  then  not  considered  of  significance.  It  has  also  been  found 
in  the  urines  of  nurslings.  Lactose,  like  glucose,  reduces  copper, 
is  dextrorotatory,  but  it  yields  a  characteristic  osazone  and  does 

'Sec  Benedict  and  Jo^lin:  Carnegie  Publication  17G,  p.  N;  also  Jour.  Am.  Them. 
Soc.,  1912,  xxxiv,  p.  928. 


184        URINE,   BLOOD   AND   RESPIRATION   IN   DIABETES 

not  ferment  with  pure  yeast  (saccharomyces  apiculatus).  However, 
the  osa/one  is  very  difficult  to  obtain  from  the  urine  and  ordinary 
yeast  is  not  to  be  depended  upon  for  the  fermentation  test. 

Jviibner's  test  is  the  most  practicable.  To  5  c.e.  of  urine  in  a 
test-tube,  add  1  or  2  grains  of  lead  acetate.  Heat  until  bubbles 
appear  and  then  add  ammonium  hydrate  until  the  color  changes. 
A  deej)  yellow  or  brown  color  in  the  solution  is  distinctive  of  lactose, 
whereas  in  the  presence  of  dextrose  the  color  is  a  cherry  red.  Prac- 
tically no  test  for  lactose  is  satisfactory. 

(//)  Pentcse  (CJIioOa). — Pentose  occasionally  is  present  in  the 
urine,  and  probably  will  be  encountered  more  frequently  in  the  future 
now  that  attention  has  been  called  to  it.  It  may  be  suspected  when 
Fehling's  test,  performed  in  the  ordinary  way,  fails  to  show  reduction 
upon  the  second  boiling,  but  later  suddenly  causes  a  partial  reduc- 
tion. Pentose  neither  ferments  nor  is  it  optically  active.  The  orcine 
test  for  pentose  is  as  follows:  To  3  c.c.  of  urine  are  added  G  c.c. 
fuming  IK!  and  a  knife-point  full  of  orcine.  Boil.  If  a  bluish- 
green  color  promptly  appears,  it  is  characteristic  of  pentose.  Urines 
containing  glucose  and  lactose  do  not  give  this  test,  but  urine  con- 
taining glycuronic  acid  produces  a  similar  color,  although  only 
after  prolonged  boiling,  and  even  then  the  precipitate  is  never 
greenish  blue,  but  more  of  a  violet  blue. 

(f)  Levulose  (C6II12O6). — Levulose  is  frequently  present  in  the 
urine  of  severe  diabetics.  It  is  not  easily  identified.  It  is  levoro- 
tatory,  but  so  is  /3-oxybutyric  acid,  which  is  found  under  similar 
conditions.  Levulose  ferments  with  yeast,  gives  a  positive  Feh- 
ling  and  Benedict  test,  and  yields  the  same  osa/one  as  does  dex- 
trose with  phenylhydra/in.  Levulose  can,  however,  be  differenti- 
ated by  the  Seliwanoff's  reaction,  provided  the  urine  does  not  con- 
tain too  high  a  percentage  of  dextrose.  SeliwanofY's  test  is  as 
follows:  To  about  f)  c.c.  of  urine  in  a  test-tube  add  1  c.c.  of  con- 
centrated hydrochloric  acid  and  a  few  crystals  of  resorcin.  Heat 
until  boiling  begins.  Upon  cooling  if  levulose  is  present  a  red 
substance  precipitates,  which  is  soluble  in  alcohol. 

A  new  method  for  the  determination  of  levulose  in  the  presence 
of  dextrose  is  described  by  Loewe.1 

(d)  Maltose  (C^IL-jOn). — Maltose  very  rarely  occurs  in  human 
urine,  and  has  not  been  shown  to  be  of  clinical  significance.  Maltose 
is  powerfully  dextrorotatory,  completely  fermented  by  yeast,  reduces 
copper  slowly,  and  yields  a  characteristic  osa/one. 

(c)  Glycuronic  Acid  ((\\\V}(.)t) . —  Glycuronic  acid  as  such  is  not 
found  in  fresh  urines,  but  conjugated  glycuronic  acids  occurring  in 
the  urine  spontaneously  decompose  and  may  cause  confusion.  Such 

1  LoewojProc.  Soc.  Exp.  Biol.  and  Mod.,  1016,  xiii,  p.  71. 


THE  EXAMINATION  OF   THE   URINE  185 

conjugated  glycuronic  acids  only  appear  after  the  ingestion  of 
chloral  hydrate,  camphor,  menthol,  turpentine,  or  phenol  in  large 
enough  quantities  to  be  of  significance.  If  this  point  is  borne  in 
mind  confusion  will  not  arise.  Glycuronic  acid  reduces  copper  and 
bismuth,  but  does  not  ferment.  It  may  be  difficult  to  detect  in  the 
presence  of  pentose,  although  one  can  rely  on  the  characteristic 
osazone  of  pentose  if  differentiation  becomes  necessary. 

(/)  Substances  Found  in  the  Urine  which  give  Rise  to  Confusion  in 
Testing  for  Sugar. — These  may  be  divided  into  two  groups:  those  in 
normal  urines  and  those  in  pathological  urines.  Of  those  met  with 
in  normal  urines  there  are  creatinin,  especially  if  the  urine  is  con- 
centrated, earthy  phosphates,  uric  acid,  xanthin  bases,  peptone, 
glycuronic  and  glycosuric  acids,  mucus,  indoxyl  sulphates,  and 
unites.  These  decolorize  the  blue  solution,  but  do  not  give  the  red 
precipitate,  which  cannot  be  mistaken.  In  pathological  urines 
albumin  is  the  most  troublesome,  but  this  is  easily  counteracted 
by  precipitating  the  albumin  by  the  Esbach  test  and  subsequently 
filtration.  In  doubtful  cases,  precipitation  of  uric  acid,  xanthin, 
hypoxanthin,  creatins,  and  phosphates  may  be  accomplished  by 
adding  5  c.c.  of  10  per  cent,  solution  of  sodium  acetate.  The  test 
is  then  applied  to  the  filtrate. 

7.  Methods  for  the  Determination  of  the  Urinary  Acids. — 
(a)  Qualitative  Tests.— (1)  Diaceiic  Acid  (CII3COCH2COOH).— 
The  simplest  method  for  the  detection  of  acidosis  by  urinary 
examination  is  Gerhardt's  ferric  chloride  reaction  for  diacetic  acid. 
The  test  may  be  performed  as  follows:  To  about  10  c.c.  of  the  fresh 
urine  carefully  acid  a  few  drops  of  an  undiluted  aqueous  solution  of 
ferric  chloride,  Liquor  Ferri  Chloric!!,  I  .  S.  P.  A  precipitate  of 
ferric  phosphate  first  forms,  but  upon  the  addition  of  a  few  more 
drops  is  dissolved.  The  depth  of  the  Burgundy-red  color  obtained 
is  an  index  to  the  quantity  of  diacetic  acid  present.  I  record  the 
intensity  of  the  reaction  as  follows :  +,  ++,  +  +  + ,  or  +  +  +  +. 

Attempts  are  sometimes  made  to  arrive  at  approximate  quanti- 
tative values  of  acid  bodies  by  the  depth  of  the  Burgundy-red  color 
obtained  in  Gerhardt's  test  for  diacetic  acid.  Liithje  pointed  out 
the  fallacies  of  this  method  and  Table  96  shows  how  unreliable 
Benedict  and  I  have  also  found  it  to  be.1 

TABLE  90. — COMPARISON  OF  DIACETIC  AC-ID  AND  /S-OXYHUTYRIC  ACID. 

Diacetic  acid,  p-oxybutyric  arid, 

symbol.  grains. 

0  5. 7  to  11.0 

+  7.0  to  14. 2 

+  +  8. 5  to  55. 3 

+  +  +  13. 3  to  51.0 

+  +  +  +  17. (>  to  36. 8 

1  Benedict  and  Joslin:    Carnegie  Institution  of  Washington,  Publication  130,  p.  25. 


ISO        n?I\E,   HLOOI)   AM)   RKHPIRATIOX   IN   DIAIIETES 

It  should  not  be  forgotten  that  if  a  patient  is  taking  salicy- 
lates,  antipyrin,  cyanates,  or  acetates,  the  foregoing  test  will  give 
a  similar  reaction,  but  one  that  cannot  be  mistaken  if  the  solution 
is  boiled  for  two  minutes.  Diacetic  acid  is  unstable  and  the  color 
disappears  if  due  to  it,  but  if  due  to  the  above  substances  the  color 
is  unchanged.  Diabetic  patients  often  take  salicylates  for  pain 
of  one  kind  or  another,  and  therefore  one  must  always  be  on  the 
watch  for  this  possibility.  I  have  seen  a  patient  on  the  verge 
of  coma  who  was  taking  salicylates,  and  at  the  start  confusion  arose 
as  to  whether  the  ferric  chloride  reaction  was  due  to  diacetic  acid  or 
to  salicyluric  acid.  With  the  test  for  diacetic  acid  the  physician 
must  be  absolutely  at  home.  It  is  doubtful  if  one  physician  in 
five  hundred  will  employ  any  better  test  for  acidosis,  and  only 
rarely  is  any  other  test  necessary.  In  confirmation  of  this  state- 
ment 1  cite  the  data  on  p.  210  which  show  the  close  correspondence 
between  the  results  of  the  ferric  chloride  test  and  determinations  of 
the  ( 'O-2  in  blood  and  alveolar  air. 

(2)  Acetone  (CHaCOnis).— The  test  for  acetone  was  the  first 
employed  for  the  detection  of  acid  poisoning,  but  the  small  role 
which  Folin1  has  shown  that  acetone  plays  in  the  total  acidosis 
led  me  to  discard  it,  believing  it  better  to  concentrate  time  upon  the 
quantitative  estimation  of  the  acidosis  than  to  use  several  qualita- 
tive tests.  Folin  demonstrated  that  most  of  the  substance  supposed 
to  be  acetone  in  the  urine  is  really  diacetic  acid,  and  that  Legal's 
test  for  acetone  is  really  a  very  delicate  test  for  diacetic  acid.  Folin 
also  pointed  out  that  the  so-called  acetone  odor  of  the  diabetic's 
breath  is  in  reality  not  due  to  acetone.-  Weiland,  quoted  by  L. 
lilum,:!  says  that  acetone  may  amount  to  1.07  grams  and  yet  the 
(ierhardt  test  for  diacetic  acid  be  negative,  while  at  other  times  the 
presence  of  0.1  gram  of  acetone  in  the  twenty-four  hours  is  sufficient 
to  make  the  Gerhardt  test  positive. 

The  different  tests  for  acetone  are  in  reality  tests  for  diacetic 
acid.  Legal's  test  is  as  follows:  A  few  crystals  of  sodium  nitro- 
prusside  are  dissolved  in  5  c.c.  of  urine,  which  is  then  rendered 
alkaline  with  sodium  hydrate.  A  few  drops  of  glacial  acetic  acid 
are  then  slowly  added  and  a  distinct  purple  color  appears,  which, 
if  the  test-tube  is  shaken,  is  best  seen  in  the  foam. 

CM  (3-o.ri/biifiinr  Arid  (CII,(<II(O11),('II,C'OOII).— There  is  no 
simple  qualitative  test  for  /3-oxybutyric  acid. 

(b)  Quantitative  Tests.-  The  determination  of  the  extent  of  the 
acidosis  is  of  prime  importance  in  the  treatment  of  any  severe  case 
of  diabetes.  1  sympathize  with  any  physician  who  must  treat  a 


THE  EXAMINATION  OF   THE   VRIXE  187 

severe  case  of  diabetes  without  a  knowledge  of  the  degree  of  acid 
poisoning  present.  Fortunately,  comparatively  simple  methods 
are  at  hand  which  are  quite  satisfactory  in  routine  treatment; 
b"+  even  most  of  these  simple  methods  are  too  complicated  for  a 
physician  with  a  large  practice  who  has.  only  a  few  eases  of  diabetes 
in  the  course  of  a  year. 

(1)  Reaction  of  Urine. — The  most  easily  performed  of  the  urinary 
tests  are  concerned  with  the  reaction  of  the  urine.  Although  the 
urines  of  normal  individuals  are  frequently  neutral  or  alkaline,  this 
is  seldom  the  case  with  urines  of  diabetics,  for  the  protein-fat  diet 
of  the  diabetic  favors  an  acid  reaction;  but  it  should  be  stated 
emphatically  that  an  acid  reaction  of  the  urine  does  not  necessarily 
imply  acidosis. 

It  has  been  proposed  to  estimate  the  degree  of  acidosis  by  deter- 
mining the  quantity  of  alkali  which  it  is  necessary  to  give  the  patient 
to  render  the  urine  alkaline.  I  do  not  recommend  this  method,  for 
I  do  not  approve  of  giving  alkalis  to  diabetic  patients  unnecessarily. 
It  is  mentioned  to  illustrate  in  a  homely  way  the  intensity  of  the 
diabetic  acidosis.  Ordinarily,  5  to  10  grams  of  sodium  bicarbonate 
will  render  the  normal  urine  alkaline,  but  in  diabetic  patients  with 
an  acidosis  of  moderate  severity  20  to  30  grams  are  required,  and  in 
severe  cases  of  acidosis  50  grams  daily  for  a  week  or  more  make 
little  impression,  and  even  with  doses  of  over  100  grams  sodium 
bicarbonate  in  twenty-four  hours  the  urines  of  patients  in  coma 
frequently  remain  acid.  A  table  has  been  constructed  by  von 
Xoorden  showing  approximately  the  quantity  of  acidosis  which 
can  be  assumed  to  be  present  when  various  quantities  of  sodium 
bicarbonate  are  required  to  render  the  urine  alkaline. 


TABLE  97. — THE  RELATION'  IJETXVEEX  THE  QUAXTITV  OK  SODIUM  BICAU- 

HOXATE  REQUIRED  TO  REXDER  THE  UKIXE  ALKALINE  AXD 

THE  ACID  BODIES  PRESENT. 


NallCOs  required  to  i 
urine  alkaline, 
grams. 

20 

30  to  40 

40  + 


'nder 


Approximate  acidosis  in  terms 

of  jg-oxybutyric  arid, 

grams. 

Under  15 

20  to  30 
30  to  40 


I  do  not  know  of  a  simpler  test  for  the  estimation  of  acidosis  in  the 
treatment  of  diabetes,  but  since  there  are  other  tests  which  do  not 
necessitate  the  giving  of  an  alkali  I  again  advise  against  its  use. 

A  more  accurate  method  of  determining  the  alkali  tolerance  has 
been  described  by  ^ellards,1  and  also  by  Palmer  and  Henderson.'2 

1  Pollards:, Johns  Hopkins  Hosp.  Bull.,  1912,  xxiii,  p.  2S9. 

2  Palmer  ;ind  Henderson:  Arch.  Int.  Med.,  1913,  xii,  p.  153. 


188       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

(2)  Ammonia. — The  quantity  of  ammonia  in  the  urine  is  a  measure 
of  the  reaction  of  the  body  to  counteract  the  acidosis  produced  in 
it.  To  this  extent  its  estimation  gives  a  more  accurate  idea  of  the 
acid  production  of  the  body  than  any  other  of  the  urinary  tests 
at  our  disposal,  which  simply  show  the  quantity  of  acid  leaving 
the  bodv,  The  test,  however,  becomes  of  less  value  so  soon  as 


AIR 

FROM 

WASHBOTTUE 


3  «->    SUCTION 


B 


Ki<;.  4. — Folia's  aeration  method  for  determination  of  ammonia  adapted  for  titration. 
Apparatus  for  use  with  suction.      (Simon.) 

extraneous  alkali  is  administered,  because  under  such  conditions 
the  ingested  alkali  is  used  by  the  body  in  preference  to  ammonia. 
The  normal  amount  of  ammonia  in  the  urine  varies  between  0.5 
to  1  gram,  and  the  ratio  between  the  ammonia  nitrogen  to  the  total 
nitrogen  in  the  urine  is  fairly  constant  at  1  to  25  (4  per  cent.).  In 
severe  diabetes  the  ammonia  may  gradually  increase,  and  in  Case 


THE  EXAMINATION  OF   THE   URINE  189 

No.  344  it  amounted  to  8  grams  in  one  day.  The  nitrogen  upon  this 
same  day  was  19.2  grams,  giving  an  ammonia-nitrogen  nitrogen 
ratio  of  34.3  per  cent.  On  another  day  this  ratio  reached  44.4  per 
cent.,  but  the  absolute  quantity  of  ammonia  was  only  4.4  grams 
and  the  nitrogen  8.7.  In  fact,  these  high  ammonia-nitrogen  nitro- 
gen ratios  are  ordinarily  only  obtained  when  the  total  quantity  of 
nitrogen  in  the  urine  is  small.  The  two  tests  which  we  have 
employed  for  the  determination  of  ammonia  follow. 

Of  the  urine  to  be  tested  1  or  2  c.c.  are  pipetted,  by  means  of  an 
Ostwald  pipette,  into  tube  .1  (Fig.  4).  Two  or  three  drops  of 
kerosene  and  a  few  drops  of  potassium  oxalate,  and  potassium  carbo- 
nate solution  (which  contains  15  per  cent,  each),  are  added  and  the 
stopper  quickly  inserted. 

By  means  of  a  suction  pump  the  ammonia  is  drawn  over  into 
tube  B,  which  contains  10  c.c.  of  j\  hydrochloric  acid.  Tube  A 
is  connected  with  a  wash  bottle  containing  10  per  cent,  sulphuric 
acid,  so  that  when  the  air  is  drawn  through  the  urine  it  will  be 
completely  ammonia-free. 

For  the  first  minute  aeration  should  be  slow,  then  the  air  current 
may  be  as  rapid  as  the  apparatus  will  stand.  Aeration  should  be 
complete  in  from  twenty  to  thirty  minutes  and  the  excess  acid  is 
titrated  with  TN¥  sodium  hydroxide.  The  amount  of  acid  used  by 
the  ammonia  times  0.0002  gives  the  amount  of  ammonia-nitrogen 
while  the  amount  of  acid  used  times  0.00024  gives  the  amount  of 
ammonia  in  the  quantity  of  urine  (1.0  or  2.0  c.c.)  used  for  the  test 
and  from  this  the  amount  of  nitrogen  or  ammonia  in  twenty-four 
hours  may  be  easily  computed. 

The  glass  tube  which  passes  nearly  to  the  bottom  of  tube  B  is 
sealed  at  the  lower  end,  but  contains  a  number  of  small  holes,  which 
allow  only  fine  bubbles  to  pass  into  the  receiving  acid  and  thus 
aids  in  the  complete  absorption  of  the  ammonia. 

This  method  is  based  on  that  of  Folin  and  Macallum.1  However, 
they  Nesslerize  and  determine  the  nitrogen  by  means  of  the  Duboscq 
colorimeter.  We  have  found  titration  reliable  and  simple. 

Honchese-Malfatti  Method  fur  the  Determination  of  Ammonia. — 
(o)  To  25  c.c.  of  urine  in  a  200  c.c.  Frlenmeyer  flask,  add  about 
25  c.c.  of  distilled  water,  about  10  grams  (1  or  2  teaspoonfuls)  of 
powdered  potassium  oxalate,  and  a  few  drops  of  indicator  (phenol- 
phthalein).  Shake  a  few  times  to  dissolve  the  oxalate,  then  titrate 
with  tenth-normal  sodium  hydroxide  until  the  first  faint  pink  color 
is  permanent. 

(b)  Take  5  c.c.  of  commercial  formalin  solution  in  a  test-tube, 
add  a  few  drops  of  phenolphthalein  indicator,  and  then  titrate  with 
tenth-normal  sodium  hydroxide  until  a  faint  pink  is  obtained. 

1  Folin  and  Macallum:  Jour.  Biol.  Chem.,  1912,  xi,  p.  423. 


100        I'lllXK,    BLOOD   AM)    IfKM'IKATlOX   L\    DIAHKTKX 

(<•}  Add  this  neutralized  formalin  to  the  urine,  which  lias  just 
been  titrated,  and  titrate  again  with  tenth-normal  sodium  hydrox- 
ide until  the  previous  pink  is  attain  obtained. 

(Calculation:  The  number  of  cubic  centimeters  of  tenth-normal 
alkali  used  in  titration  (<•)  multiplied  by  0.0017  gives  the  number 
of  grains  of  ammonia  in  '2~i  c.c.  of  urine.) 

Xo  account  need  be  taken  of  the  amount  of  sodium  hydroxide 
used  in  titrutions  (a)  and  (/>). 

The  method  depends  upon  the  fact  that  formalin  combines  with 
free  XI I3  and  forms  hexamethylenetetramin.  The  ammonia  is 
liberated  from  its  salts  by  means  of  XAOII. 

(o)  p-o.ry1nrti/ric  Acid.— The  tests  for  /3-oxybutyric  acid  are  all 
complicated,  because  they  depend  upon  the  extraction  of  the 
acid.  Estimation  of  the  fi-oxy butyric  acid  based  upon  the  difference 
between  the  quantity  of  sugar  as  determined  by  Fehling's,  fermen- 
tation and  polarization  tests  are  inaccurate.  They  simply  suggest 
the  presence  of  /3-oxybiityric  acid. 

llhiclc'x  Method.— One  hundred  cubic  centimeters  of  urine  are 
measured  with  a  pipette  into  an  evaporating  dish  and  made  dis- 
tinctly alkaline  by  the  addition  of  .sodium  bicarbonate.  The  urine 
is  then  evaporated  to  a  thick  syrupy  liquid  (4  or  f>  c.c.),  using  the 
gentle  heat  of  a  water-bath  or  the  low  heat  of  an  electric  stove. 
After  cooling  the  residue  is  made  distinctly  acid  with  strong  hydro- 
chloric acid,  and  is  then  formed  into  a  thick  paste,  and  later  into 
a  porous  meal  by  the  gradual  addition  of  plaster  of  Paris.  This 
porous  meal  is  placed  in  an  extraction  apparatus  (a  Soxhlet  or  a 
modification  of  it)  and  extracted  with  about  00  c.c.  of  ether  for  three 
hours.  The  ether  extract  is  then  transferred  to  an  evaporating  dish, 
where  the  ether  is  allowed  to  evaporate  spontaneously.  The  residue 
is  treated  with  .">  c.c.  of  water  and  0.4  gram  of  bone-black  added  to 
decolorize,  then  filtered,  and  washed  until  perfectly  clear  and  made 
up  to  a  known  volume,  usually  LT)  c.c.  '[  he  (8-oxybutyric  acid  is 
determined  with  a  polariscope,  using  the  following  formula: 


Shaffer'*  Method  for  j3-o.i't/l>i<ti/>/c  Acid,  ^Icctotic  mid  Di&cctic 
Add  Combined.-  The  advantage  of  this  method  is  that  it  not  only 
enables  the  j3-o.\ybutyric  acid  to  be  determined,  but  the  acetone 
and  diacetic  acid  as  well.  'The  test  is  well  described  by  Sahli:1 
"  Introduce  into  a  ")()()  c.c.  volumetric  ilask  :_'.">  to  LMO  c.c.  of  the  urine 

1  Sahli:  Diagnostic  Methods,  I'.tl  1,  W.  H.  Saunders.  Company,  Philadelphia,  trans- 
luted  by  Nathaniel  Bowditch  Potter. 


THE  EXAMINATION  OF   THE   URINE  191 

to  be  examined.  The  amount  of  urine  used  will  depend  upon  the 
i'.niount  of  (8-oxybutyric  acid  which  is  contained  in  it.  In  the  ease 
of  urines  giving  a  strong  ferric  chloride  reaction,  25  to  50  c.c.  of 
urine  will  suffice.  It  is  desirable  to  use  such  a  volume  of  urine  as 
will  give  25  to  50  ing.  of  acetone.  To  the  urine  is  added  an  excess 
of  basic  lead  acetate  and  10  c.c.  of  ammonium  hydroxide.  It  is 
necessary  to  be  sure  that  an  excess  of  the  lead  salt  has  been  added. 
The  mixture  is  made  up  to  the  500  c.c.  mark,  shaken  thoroughly 
and  filtered  through  a  dry  filter-paper;  200  c.c.  of  the  filtrate  are 
distilled  after  the  addition  of  300  to  400  c.c.  of  water  and  15  c.c. 
of  concentrated  sulphuric  acid  and  a  little  talcum  to  prevent  bump- 
ing. About  200  to  250  c.c.  of  distillate  are  collected.  This  distillate 
contains,  in  addition  to  acetone  from  the  preformed  acetone  and 
aceto-acetic  acid,  certain  volatile  acids.  If  it  be  made  slightly 
alkaline  and  a  second  distillation  made,  the  distillate  will  contain 
all  the  acetone  from  acetone  and  aceto-acetic  acid,  and  this  may 
be  estimated  by  the  iodin  method. 

"The  residue  from  the  urine  containing  the  sulphuric  acid  con- 
tains all  the  /3-oxybutyric  acid,  and  must  now  be  converted  by 
this  oxidation  into  acetone.  The  residue  is  diluted  and  0.5  gin. 
of  potassium  dichromate  added.  It  is  then  distilled  from  a  flask 
provided  with  a  dropping  funnel  and  water  added  gradually  to 
make  up  for  the  amount  distilled  over.  Instead  of  water,  one  may 
use  a  0.5  per  cent,  solution  of  potassium  dichromate.  After  about 
500  c.c.  of  distillate  have  been  collected  the  distillate  is  redistilled 
after  the  addition  of  20  c.c.  of  3  per  cent,  hydrogen  dioxide  and 
sufficient  potassium  hydroxide  to  make  the  solution  alkaline. 
Collect  300  c.c.  of  distillate  and  estimate  the  amount  of  acetone 
with  iodine  and  thiosulphate ;  1  mg.  of  acetone  is  equivalent  to  1 .704 
nig.  of  (S-oxybutyric  acid.1" 

(4)  Acetone  and  Diuretic  Acid  (The  Huppert-Messinger  Quanti- 
tative Method).-  "This  method  determines  the  sum  of  acetone'  and 
the  diacetic  acid,  which  is  transformed  to  acetone  by  the  distillation. 

The  solutions  necessary  are-: 

1.  Acetic    acid,    50    per    cent. 

2.  f^-  iodine  solution. 

.').  -j^-  sodium  thiosulphate  solution. 

4.  A  thin  starch  solution  (1  gram  of  starch  dissolved  in  500  c.r. 
of  boiling  water). 

"To  make  up  these  solutions  24. S  grams  of  crystallized  sodium 
thiosulphate  (XaaSgOa  +  5H20)  are  carefully  weighed,  dissolved 
in  distilled  water,  and  the  solution  made  up  accurately  to  one 
liter.  Next  25  grams  of  potassium  iodide  are  dissolved  in  a  little 


192        i'ltIXE,   BLOOD   AM)   RESI'Ih'ATIOX  IN   DIABETES 

water,  12.7  grams  of  iodine  added,  and  the  solution  made  up  to 
about  (JOO  to  !)")()  e.e.  To  standardize  tin's  solution  20  c.e.  of  the 
thiosulphate  solution  are  carefully  measured  into  a  small  flask,  a 
fe\v  dro])s  of  the  starch  solution  added,  and  then  the  iodine  solution 
added  from  a  burette  with  glass  stop-cock  until  the  blue  color  just 
appears.  This  titration  is  repeated  several  times  until  the  amount 
necessary  for  the  end-reaction  is  accurately  determined,  then  to  the 
iodine  solution  is  added  the  necessary  amount  of  water,  so  that 

20  c.c.  of  this  solution  will  exactly  equal  20  c.c.  of  the  thiosulphate 
solution.     This   dilution    should    be   confirmed    by   an   additional 
titration. 

"Both  of  these  fluids  are  to  be  kept  in  dark  glass  bottles  with 
ground-glass  stopjx'rs.  The  iodine  solution  must  be  restandardized 
frequently.  One  cubic  centimeter  of  the  thiosulphate  solution 
equals  0.0127  gram  of  iodine.  The  formula  of  the  reaction  is 

21  +  2Xa2S2();i  -f  2Xal  =  Xa2S.,O6.    The  first  free  iodine  in  excess 
will  form  the  blue  starch  iodine  compound. 

"The  urine  if  alkaline  is  first  just  acidified  with  acetic  acid.  To 
500  c.c.  of  acid  urine  (if  rich  in  acetone,  c.  </.,  a  febrile  urine,  100 
c.c.  or  even  less)  is  added  50  per  cent,  acetic  acid,  exactly  2  c.c. 
per  100  c.c.  of  urine.  The  urine  is  then  distilled  until  only  about 
one-tenth  the  volume  remains.  The  flask  receiving  the  distillate 
is  tightly  closed  by  a  stopper  with  two  perforations.  Through  one 
of  these  passes  the  tube  from  the  distilling  flask,  and  this  tube  reaches 
to  the  bottom  of  the  flask  and  dips  below  the  surface  of  water 
previously  placed  there;  through  the  other  passes  a  shorter  tube 
connected  with  a  bulb  or  1'eligot  I  -tube  filled  with  water,  which 
acts  as  a  safety  bulb  to  prevent  the  loss  of  any  of  the  very  volatile 
acetone.  This  receiving  flask  is,  during  the  distillation,  surrounded 
by  ice.  When  the  urine  is  distilled  down  to  about  one-tenth  its 
original  volume  the  distilling  flask  is  disconnected  before  the  heat, 
is  removed,  else  the  distillate  will  '"strike  back."  The  tube  of  the 
cooler  is  then  washed  through  with  distilled  water  to  wash  into  the 
receiving  flask  the  last  trace  of  distillate.  The  water  in  the  safety 
bulb  or  I'-tuhe  is  emptied  in  too,  and  the  tube  washed  and  this 
water  added  to  the  distillate. 

''Some  calcium  carbonate  is  then  added  to  the  distillate  which  is 
then  well  shaken.  This  is  to  remove  any  nitrous  and  formic  acid 
which  may  have  distilled  over.  The  distillation  is  then  repeated  as 
before. 

"To  this  second  distillate  (to  which  is  again  added  the  water  in 
the  safety  tube  and  the  wash-water  from  both  tubes)  is  added 
1  c.c.  of  dilute  sulphuric  acid  (  1  to  S  of  water)  and  the  distillation 
again  repeated. 

"This  final  distillate  is  poured  into  a  flask  or  measuring  cylinder 


THE  EXAMINATION   OF   THE    URINE  193 

with  ground-glass  stopper.  (Or,  indeed,  this  flask  or  cylinder  may  be 
used  to  receive  the  distillate  during  the  distillation.  It  is,  of  course, 
protected  as  in  the  first  distillation.)  A  large  excess  of  carefully 
measured  ^  iodine  solution  is  added,  these  fluids  well  shaken,  and 
then  an  excess  of  strong  nitrite-free  XaOII  or  KOII  added  drop 
by  drop.  The  flask  is  closed,  shaken  for  one-quarter  of  a  minute, 
and  then  allowed  to  stand  for  five  minutes.  The  vessel  used  must 
be  so  large  that  its  contents  will  now  not  more  than  one-third  fill  it. 

"The  stopper  is  then  removed  (and  all  fluid  clinging  to  it  washed 
back  into  the  flask),  the  contents  of  the  flask  are  then  made  acid 
with  concentrated  hydrochloric  acid,  and  the  excess  of  iodine 
determined  by  titration.  The  f^  thiosulphate  solution  is  added 
from  a  burette  until  the  mixture  is  only  slightly  yellow,  then  a  few 
cubic  centimeters  of  the  starch  solution  are  added  and  the  addition 
of  thiosulphate  solution  continued  until  the  blue  color  just  disappears. 
If  a  little  too  much  thiosulphate  is  added,  one  adds  a  measued 
amount  of  iodine  and  continues  the  titration  until  the  end-reaction 
is  reached;  1  c.c.  of  the  iodine  solution  equals  0.967  mg.  of  acetone 

"The  results  of  this  method  are  from  4  to  8  per  cent,  too  low. 
The  final  distillate  must  contain  no  phenol,  ammonia,  nitrous  or 
formic  acids,  for  all  of  these  except  nitrous  acid  will  cause  the  loss 
of  some  iodine  while  that  will  set  iodine  free.  In  this  method  the 
error  from  ammonia  is  prevented  by  addition  to  the  just-acid 
urine  of  2  c.c.  of  acetic  acid  per  100  c.c.  of  urine.  If  a  mineral  acid 
or  5  c.c.  of  acetic  per  100  c.c.  of  urine  were  used,  none  of  the  ammonia 
would  reach  the  distillate,  but  some  phenol  would.  For  this  reason 
only  2  c.c.  of  acetic  per  100  c.c.  of  urine  are  added  and  the  trace 
of  ammonia  which  docs  distil  over  is  later  removed  by  the  third 
distillation  after  the  addition  of  sulphuric  acid.  The  addition  of 
calcium  carbonate  to  the  first  distillate  will  remove  the  nitrous  and 
formic  acids. 

"It  is  wise  to  add  the  alkali  and  the  iodine  solution  to  the  final 
distillate  without  shaking  much,  and  to  notice  whether  the  fluid 
separating  these  two  partial  layers  turns  at  all  black.  If  so,  ammonia 
is  present  and  the  specimen  should  be  thrown  away.  If  none  is 
indicated  the  fluid  is  shaken,  etc. 

"An  easier  and  fairly  satisfactory  determination  may  be  made  as 
follows:  From  50  to  250  c.c.  of  urine  are  distilled  until  the  great 
mass  of  water  is  passed  over.  To  the  end  of  the  tube,  which  should 
have  a  good  cooler,  is  attached  a  rubber  tube,  the  end  of  which  dips 
into  water  in  the  receiving  flask.  A  little  acid  may  be  added  to 
prevent  foaming. 

"The  distillate  is  poured  into  a  graduated  cylinder  with  a  ground- 
glass  stopper,  an  excess  (15  to  20  c.c.)  of  XaOII  added,  and  then 
20  c.c.  of  Lugol's  solution,  which  is  conveniently  made  three  times 
13 


194        U1UXE,    BLOOD   AXD   UKM'lltATIOX    IX    DIABETES 

the  ordinary  strength.  A  heavy  black  precipitate  forms  which  soon 
clears,  leaving  a  yellow  sediment  of  iodoform  crystals.  After 
standing  for  some  time,  te.n  to  fifteen  minutes  or  more,  about 
10  to  .";()  c.c.  of  ether  are  added  and  the  fluid  shaken  out  until  the 
ether  contains  all  of  the  iodoform.  A  reading  is  then  made  of  the 
volume'  of  ether,  10  c.c.  are  removed  in  a  graduated  pipette  and 
evaporated  in  the  air  in  a  weighed  glass  dish.  This  is  then  dried 
over  sulphuric  acid  and  the  dish  again  weighed.  The  weight  of  the 
iodoform  multiplied  by  0.147  equals  the  weight  of  acetone  repre- 
sented in  the  number  of  cubic  centimeters  used.  That  of  the  whole 
ether  extract  may  then  be  reckoned." 

Quantitative  Estimation  of  Acetone  Alone  (Folin1). — The  above 
method  gives  the  sum  of  the  acetone  and  diacetic  acid  in  terms  of 
acetone.  Folin's  method  is  the  only  one  which  allows  an  estimation 
of  the  acetone  alone.  The  acetone  is  separated  from  the  urine 
by  apparatus  which  Folin  has  introduced  for  ammonia  estima- 
tions (see  page  JSS).  Twenty-five  cubic  centimeters  of  urine  are 
measured  into  the  aerometer  cylinder,  from  0.2  to  O.o  gram  of 
oxalic  acid  or  a  few  drops  of  10  per  cent,  phosphoric  acid,  and  S  to 
10  grams  of  sodium  chloride  and  a  little  petroleum  are  added.  In 
the  absorbing  bottle  has  been  placed  water  to  which  is  added  40  per 
cent,  potassium  hydroxide  solution  (10  c.c.  per  150  c.c.  of  the  water) 
and  an  excess  of  the  standardized  iodine  solution.  The  apparatus 
is  then  connected  with  a  ( 'hapman  air  pump  and  a  fairly  strong  (yet 
not  so  strong  as  for  an  ammonia  determination)  air  current  drawn 
through  for  twenty  to  twenty-five  minutes.  Every  trace  of  acetone 
will  be  removed  from  the  urine  and  converted  in  the  receiving  bottle 
to  iodoform.  The  contents  of  the  receiving  bottle  are  acidified  with 
concentrated  hydrochloric;  acid  (10  c.c.  for  each  10  c.c.  of  alkali 
used)  and  the  excess  of  iodine  titrated  with  standard  thiosulphate 
solution  and  iodine,  as  in  the  Messinger  method.  The  observer 
must  be  thoroughly  acquainted  with  his  air  current  and  apparatus 
by  repeated  experiments  with  pure  acetone. 

\  <in  Klyke-Fitz  Method*  for  Determination  of  fi-hydroxylntlyric 
Acid,  Diacetic  Acid  and  Ardour  in  I  nur  and  Blond.--  For 
the  following  simplified  method  for  the  determination  of  /3-hydroxy- 
bntyric,  diacetic  acid  and  acetone  in  the  blood  and  urine  I  am 
greatly  indebted  to  1 'odors  Van  Slyke  and  Fit/,  of  the  Rockefeller 
Institute  for  Medical  Research.  The  methods  are  based  on  a 
combination  of  Shaffer's  principle  of  oxidizing  hydroxybntyric 
acid  to  acetone,  and  of  I  Vnige's  method  for  precipitating  acetone 
as  a  basic  mercuric  sulphate  compound.  Oxidation  and  precipita- 
tion are  carried  out  simultaneously  in  the  same  solution,  so  that  the 

1  Folin:    .lour.  Hiol.  ("hem.,  May,  1007,  iii,  j>.  177. 


THE  EXAMINATION   OF   THE    URINE  105 

technic  is  simplified  to  boiling  the  mixture  for  an  hour  and  a  half 
under  a  reflux  condenser,  and  weighing  the  precipitate  which  forms. 
Neither  the  size  of  sample  nor  mode  of  procedure  have  required 
variation  for  different  urines;  the  same  process  yields  accurate 
results  for  the  smallest  significant  amounts  of  acetone  bodies  and 
likewise  for  the  largest  that  are  encountered.  The  precipitate  is 
crystalline  and  beautifully  adapted  to  drying  and  accurate  weigh- 
ing; but  when  facilities  for  weighing  are  absent  the  precipitate  can 
be  redissolved  in  5  per  cent,  hydrochloric  acid  and  the  mercury 
titrated  by  a  suitable  method,  such  as  that  of  Personnel 

Solutions  llequ ired. 

Twenty  Per  Cent.  Copper  Sulphate. — Two  hundred  gms.  of  C'uSO4.5 
aqua  dissolved  in  water  and  made  up  to  1  liter. 

Ten  Per  Cent.  Mercuric  Sulphate. — Seventy-three  gms.  of  C'.P.  red 
mercuric  oxide  dissolved  in  1  liter  of  HoSOtof  4  normal  concentration. 
The  solution  of  the  oxide  is  assisted  by  warming  on  a  steam  bath. 

Fifty  Volume  Per  Cent.  Sulphuric  Acid. —  Five  hundred  c.c.  of 
sulphuric  acid  of  1.835  specific  gravity,  diluted  to  1  liter  with  water. 
Concentration  of  HoSCX  should  be  17  normal. 

Colloidal  Iron. — Merck's  "Dialyzed  Iron"  solution  containing  5 
per  cent,  of  Fe2O.3. 

Ten  Per  Cent.  Calcium  Hydrate  Suspension. — Mix  100  gms.  of 
Merck's  fine  light  "Reagent"  Ca(OH)2  with  1  liter  of  water. 

Five  Per  Cent.  Potassium  Dichromate. — Fifty  gms.  K2(  r2O7  dis- 
solved in  water  and  made  up  to  1  liter. 

Removal  of  Clucose  and  Other  Interfering  Substances  from  Urine. — 
Place  25  c.c.  of  urine  in  a  250  c.c.  measuring  flask.  Add  100  c.c.  of 
water,  50  c.c.  of  copper  sulphate  solution  and  mix.  Then  add  50  c.c. 
of  10  per  cent,  calcium  hydrate,  shake  and  test  with  litmus.  If 
not  alkaline,  add  more  calcium  hydrate.  Dilute  to  mark  and  let 
stand  at  least  one-half  hour  for  glucose  to  precipitate.  Filter 
through  a  dry  folded  filter.  This  procedure  will  remove  up  to  S  per 
cent,  of  glucose.  Urine  containing  more  should  be  diluted  enough 
to  bring  the  glucose  down  to  8  per  cent.  The  filtrate  may  be  tested 
for  glucose  by  boiling  a  little  in  the  test-tube.  A  precipitate  of 
yellow  CuoO  will  be  obtained  if  the  removal  has  not  been  complete. 
White  CaCos  precipitate  means  nothing. 

Removal  of  Proteins  from  Blood  and  Llasma. — Of  whole  blood  10  c.c. 
are  measured  into  a  250  c.c.  volumetric  flask,  half-full  of  water. 
Sixty  c.c.  of  colloidal  iron  are  added  and  mixed,  then  1  c.c.  of  satu- 
rated sodium  sulphate  solution.  The  flask  is  filled  to  the  mark  and 
shaken.  The  contents  are  filtered  through  a  dry  folded  filter. 

1  Sutton's  Volumetric  Analysis,  10th  edition,  p.  264. 


196       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

For  plasma  the  procedure  is  the  same  except  that  only  8  c.c.  are 
taken  in  a  200  c.c.  flask  with  15  c.c.  of  colloidal  iron,  and  1  c.c. 
of  saturated  sodium  sulphate. 

In  the  case  of  either  whole  blood  or  serum,  125  c.c.  of  filtrate, 
equivalent  to  5  c.c.  of  the  original  sample  are  taken  for  analysis. 

Simultaneous  Determination  of  Total  Acetone  liodiex  (Acetone, 
Diacetic  Acid  and  /3-oxybutyric  Acid),  of  Urine  or  Blood  in  One 
Operation. — Place  in  500  c.c.  Erlenmeyer  25  c.c.  of  urine  filtrate 
plus  100  c.c.  of  water  or  125  c.c.  of  blood  filtrate.  Add  10  c.c.  of 
50  per  cent,  sulphuric  acid  and  35  c.c.  of  the  10  per  cent,  mercuric 
sulphate.  Connect  the  flask  with  a  reflux  condenser  having  a 
straight  condensing  tube  of  8  or  10  mm.  diameter,  and  heat  to 
boiling.  After  boiling  has  begun,  add  5  c.c.  of  the  5  per  cent, 
dichromate  through  the  condenser  tube.  Continue  boiling  gently 
one  and  one-half  hours.  The  precipitate  which  forms  consists  of 
the  mercury  sulphate  compound  of  the  preformed  acetone  and  of 
the  acetone  which  has  been  formed  by  oxidation  of  the  hydroxy- 
butyric  acid.  It  is  collected  in  a  Gooch  or  a  medium  density 
"alundum"  crucible,  washed  with  200  c.c.  of  cold  water,  followed 
by  a  little  95  per  cent,  alcohol,  dried  for  an  hour  at  1 10°  and  weighed. 
Several  precipitates  may  be  collected,  one  above  the  other,  without 
cleaning  the  crucible. 

Acetone  and  Diacetic  Acid. — These  substances  without  the 
hydroxybutyric  acid  are  determined  exactly  as  the  total  acetone 
bodies,  except  that  (1)  no  dichromate  is  added  to  oxidize  the 
hydroxybutyric,  and  (2)  the  boiling  must  continue  for  not  less  than 
thirty-five  nor  more  than  forty-five  minutes.  Boiling  for  more  than 
forty-five  minutes  splits  olf  a  little  acetone  from  hydroxybutyric 
acid  even  without  dichromate. 

^-hydroxybutyric  Acid  in  Urine. — The  /3-hydroxybutyric  acid 
alone  is  determined  exactly  as  total  acetone  bodies  except  that  the 
preformed  acetone  and  that  from  the  diacetic  acid  are  first  boiled 
off.  To  do  this  the  25  c.c.  of  urine  filtrate  plus  125  c.c.  of  water  are 
treated  with  2  c.c.  of  50  per  cent,  sulphuric  acid  and  boiled  in  the 
open  flask  for  ten  minutes.  The  volume  of  solution  left  in  the  flask 
is  measured  in  a  cylinder.  The  solution  is  returned  to  the  flask, 
and  the  cylinder  washed  with  enough  water  to  replace  part  of  that 
boiled  off  and  bring  the  volume  of  the  solution  to  127  c.c.  Then 
8  c.c.  of  the  50  per  cent,  acid  and  35  c.c.  of  the  10  per  cent,  of  mercuric 
sulphate  are  added.  The  flask  is  connected  under  the  condenser 
and  the  determination  is  continued  as  above. 

fi-hydroyybutyric  Add  in  Mood.-  The  following  procedure 
enables  one  to  determine  separately  in  a  single  sample  of  blood  both 
the  acetone  plus  diacetic  acid  and  the  /3-acid.  The  acetone  and 
diacetic  acid  are  precipitated  as  above  described,  and  the  filtrate 


THE  EXAMINATION  OF   THE   URINE 


197 


poured  as  completely  as  possible  through  the  Gooeh  or  alundum 
crucible  into  a  dry  receiving  flask.  Of  this  filtrate  !(>()  c.c.  are 
measured  into  another  Erlenmeyer  flask  and  10  c.c.  of  water  are 
added.  The  mixture  is  heated  to  boiling  under  a  reflux  condenser, 
5  c.c.  of  dichromate  solution  are  added,  and  the  determination 
continued  as  described  for  "total  acetone  bodies." 

In  case  only  the  /3-acid  is  desired,  or  enough  blood  is  taken  for 
double  portions,  the  slightly  easier  procedure  used  for  urine  may 
also  be  followed  with  blood. 

Factors  for  Calculating  Acetone  Bodies  in  Urine  when  25  c.c.  of 
Filtrate,  Equivalent  to  2.5  c.c.  of  Urine,  and  in  Blood  when  125  c.c. 
of  Filtrate,  Equivalent  to  5  c.c.  of  Blood  are  Used  for  Determination. — 
One  mgm.  of  /3-hydroxybutyric  acid  yields  8.7  mgm.  of  precipitate. 
One  mgm.  of  acetone  yields  19.7  mgm.  of  precipitate. 

The  amount  of  precipitate  obtained  from  /3-hydroxybutyric 
acid  therefore  corresponds  to  79  per  cent,  of  the  acetone  that 
would  be  obtained  if  each  molecule  of  hydroxybutyric  yielded  a 
molecule  of  acetone.  The  oxidation  is  complete  in  one  and  one-half 
hours,  and  the  conditions  are  so  constant  that  duplicates  usually 
check  within  1  per  cent. 


TABLE  98. — FACTORS  BY  WHICH  MILLIGRAMS  OF  PRECIPITATE  ARE  MULTIPLIED 
IN   ORDER  TO  GIVE  RESULTS  CALCULATED  AS: 


/3-hydroxybutyric 

Acetone. 

Molecular 

acid. 

[ 

C  c    M 

o.c.   1()- 

Molecular 

Determination. 

Gins,  per 

Mg.  per 

Cms.  per 

MR.  per 

acctonc 

concentra- 

liter, 

100  c.c., 

liter, 

100  c.c., 

or  /3-ao.id 

tion  in 

urine. 

blood. 

urine. 

blood. 

per  liter, 

blood  or 

urine. 

plasma. 

Total  acetone  bodies' 

0.0428        2.14 

0.023S 

1.19 

4.11 

0  .  000206 

( 
/3-hydroxybutyrie-      .       .    < 

0.0460 

2.30 

(2.44) 

0  .  0256 

1.28 
(1.37) 

4.42 

0.000221 
0.000235 

Acetone  and  diacetic  acid 

0  .  0304 

1.82 

0.0203 

1.015 

3.50 

0.000175 

'The  "total  acetone  body"  factors  are  calculated  on  the  assumption  that  the 
molecular  ratio  (acetone  plus  diacetic  acid) :  (/3-hydroxybutyric  acid)  is  1:2.  Because 
the  hydroxybutyric  yields  on  oxidation  only  0.79  molecule  of  acetone,  the  "total 
acetone  body"  factor  is  absolutely  accurate  only  when  the  above  ratio  is  1:2.  But 
with  the  range  of  mixtures  encountered  in  acetonuria,  when  the  ratio  is  usually 
between  1:2  and  1:3,  with  extreme  Hurts  of  1:1  and  1:4,  the  use  of  the  above 
approximate  factors  for  "total  acetone  bodies"  will  seldom  involve  a  significant 
error.  The  actual  errors  in  percentages  of  the  amounts  determined  are  as  follows: 
ratio  1:1,  error  3.7  per  cent.;  ratio  1:2,  error  zero;  ratio  1:3,  error  1.9  per  cent.; 
ratio  1:4,  error  3  per  cent. 

170 

2  The  factors  in  parenthesis  are  the  usual  factors  X  ,™>  and  are  for  use  in  deter- 
mination of  /3-hydroxybutyric  acid  in  blood  when  the  acetone  is  precipitated  and 
the  /3-acid  determined  in  160  c.c.  of  the  filtrate. 


IDS        I'h'IXK,   BLOOD   A\l)   ItKM'IHATlOX    IX   DIABETES 

S.  Nitrogen.-  The  determination  of  the  nitrogen  in  tlie  urine  is 
valuable  l)eeanse  it  furnishes  an  index  to  the  quantity  of  protein 
which  the  patient  is  disintegrating.  Incidentally,  this  is  the*  easiest 
way  to  determine  the  quantity  of  protein  in  the  diet.  Since  nitrogen 
constitutes  10  per  cent,  of  the  protein  molecule,  we  can  multiply 
the  quantity  of  nitrogen  obtained  in  the  urine  by  (>}  to  obtain  the 
protein  which  it  represents.  \Ye  shall  not  be  far  wrong  if  to  this 
we  add  1  or  "2  grams  of  nitrogen  (0  to  12  grams  protein)  to  offset 
the  nitrogen  of  the  feces,  and  consider  this  total  quantity  as  repre- 
senting the  protein  in  the  food.  The  determination  of  the  nitrogen 
is  also  valuable  because  it  is  often  useful  to  know  the  ammonia- 
nitrogen  nitrogen  ratio  as  well  as  the  dextrose-nitrogen  ratio. 
The  Kjeldahl  test  for  nitrogen  is  the  one  often  employed,  but  the 
method  used  by  Dr.  Ragle  in  my  laboratory  based  upon  that  of 
Folin  requires  less  time  and  is  reliable. 

Formerly  large  quantities  of  nitrogen  were  obtained  in  the 
urines  of  diabetic  patients,  but  modern  treatment  with  its  restriction 
of  protein  makes  these  excessive  quantities  rare. 

Recently,  however,  I  have  met  with  three  such  examples:  thus, 
Case  Xo.  Oo2  came  to  me  upon  a  supposedly  restricted  diet,  and  the 
nitrogen  in  the  urine  amounted  to  20.2")  grams.  The  diminution  of 
protein  in  the  diet  removed  the  sugar  entirely  from  the  urine,  even 
though  12  grams  of  carbohydrate  were  added  in  the  form  of  oatmeal. 
Case  Xo.  (')l(')  was  not  sugar-fret1  before  her  entrance  to  the  hos- 
pital, but  in  the  hospital  easily  became  so.  The  urine  upon  March 
IS,  11) KS,  amounted  to  001f>  c.o.,  and  contained  4S.">  grams  sugar 
and  07.0  grams  nitrogen.  She  entered  the  hospital  May  22,  10K>, 
and  the  urine  was  free  from  sugar  May  2">.  Five  months  sub- 
sequently the  urine  was  examined  and  the  quantity  of  nitrogen 
in  the  twenty-four  hours  amounted  to  J'>0  grams.  Case  Xo.  1100 
has  already  been  discussed  in  connection  with  the  volume  of  the 
urine  (  see  p.  1 70),  and  will  be  referred  to  more  extensively  on  p.  )>70. 

A  daily  analysis  for  nitrogen  is  expensive,  but  it  is  a  simple 
matter  to  aliquot  specimens  of  urine  for  a  week  and  then  obtain 
the  average  nitrogen  excretion  per  day. 

Two  or  three  admirable  methods  are  available  for  the  determina- 
tion of  total  nilrogen  in  urine  provided  a  completely  equipped 
laboratory  is  at  hand.  Folin's  a  ("'ration  method'  requires  besides  the 
usual  apparatus  an  air  current  and  a  Duboscq  colorimeter.  Bene- 
dict has  modified  this  method  and  distils  the  ammonia.  For  two 
years  my  former  assistant,  B.  II.  Ragle,  now  of  the  Massachusetts 
(Jeneral  Hospital,  has  used  a  method  which  he  devised,  and  it  has 
been  found  accurate  and  rapid.  The  ordinary  straight  Jena  glass 

1  Folia  and  Farmer:    Jour.  liiol.  Chciu.,  l'.H2,  xi,  p.  -UK*. 


THE  EXAMINATION  OF  THE   URINE 


199 


tube  200  x  2  mm.,  is  perfectly  satisfactory  for  Folin's  aeration 
method  but  unsatisfactory  for  distillation.  Jn  September,  1914, 
\ve  had  Eimer  &  Amend,  of  New  York,  blow  us  the  simple  tube  of 
heavy  Jena  glass  as  shown  in  the  diagrams.  By  a  slight  modifi- 
cation of  the  distillation  frame  one  can  use,  instead  of  these  special 
Jena  glass  tubes,  Erlenmeyer  flasks  of  250  c.c.  capacity — made  of 
non-sol  glass,  and  these  we  now  employ. 

Digestion  and  distillation  are  carried  out  as  follows:  1  c.c.  of  the 
urine,  diluted  1  to  ">,  is  pipetted  by  means  of  an  Ostwald  pipette 
into  one  of  the  special  tubes,  according  to  Folin.  Add  1  c.c.  of 


FIG.  n. — Oxidation  tube  with  Folio's  fumo  absorber. 

concentrated  sulphuric  acid,  1  gram  of  potassium  sulphate,  one 
drop  of  10  per  cent,  copper  sulphate,  and  a  small  pebble  or  glass 
bead.  Digest  over  a  micro-burner  and  allow  to  cool  until  the 
digestion  mixture  just  becomes  viscous,  then  add  about  10  to  12  c.c. 
of  water,  a  drop  of  alizarin  indicator,  and  a  pinch  of  talcum  powder. 
Transfer  to  distilling  frame  and  after  connecting  as  in  diagram, 
stopper  tightly.  A  glass  tube  should  perforate  the  one-hole  stopper 
and  reach  almost  to  the  bottom  of  the  tube.  (Figs.  5  and  (>.) 

Start  the  micro-burner  under  the  tube  and  then  by  means  of  a 
pipette,  and  by  releasing  the  stop-cock  at  A,  introduce  )>  or  4  c.c. 
of  40  per  cent,  sodium  hydroxide.  This  will  be  sufficient  to  render 


200       I'RINE,   BLOOD  AXD  RESPIRATION  IN   DIABETES 

strongly  alkaline,  and  the  ammonia  is  now  quickly  forced  over  into 
]()  to  20  c.c.  of  -7N',j  hydrochloric  acid. 

In  six  to  eight  minutes  all  the  ammonia  will  have  been  driven 
over  and  the  excess  acid  is  titrated  with  7Nff  sodium  hydroxide. 

liable  uses  the  -^  solutions  and  I  c.c.  of  urine  in  his  determinations 
in  order  to  simplify  the  computation. 

One  cubic  centimeter  of  7N0  hydrochloric  acid  :=  0.0002  gram 
nitrogen. 

If  S  c.c.  of  the  acid  are  neutralized  by  the  ammonia  the  calculation 
is  (S  x  0.0002  x  ,">  x  1000  (c.c.  in  24°  amount)  =  8  grams  nitrogen. 


Fie.  G. — A  micro-Kjcldahl  movable  distillation  frame  designed  for  small 
laboratories  by  J3.  II.  Ha^le. 

0.  Albumin. — The  test  for  albumin  in  the  urine  should  be  per- 
formed at  frequent  intervals  during  the  care  of  diabetic  patients. 
Too  often  the  diagnosis  of  diabetes  leads  us  to  neglect  the  general 
treatment  of  the  case.  Case  No.  I]47,  already  cited  (p.  170),  is  only 
too  poignant  an  illustration  of  this  tendency. 

10.  Casts. —  From  the  time  of  Kiilz  the  irritation  of  the  kidneys 
in  the  first  stages  of  diabetic  coma  has  been  observed.  Over  and 
over  again  I  have  seen  typical  "showers"  of  casts  at  the  beginning 
of  diabetic  coma.  They  may  occur  at  times  when  the  albumin 
in  the  urine  amounts  to  the  slightest  possible  trace.  Casts  in  the 
urine,  even  though  occurring  in  showers,  do  not  necessitate  the 
development  of  fatal  coma,  for  these  were  found  in  the  urine  of 
Case  No.  705  on  December  0-7,  1915.  (See  Table  99.) 


THE  EXAMINATION  OF   THE   URINE 


201 


TABLE  99. — CASE  No.  765.     SEVEKE  ACIDOSIS;  "SHOWERS"  OF  CASTS 
WITHOUT  COMA. 


Date. 

\"^'    ,  Albumin. 

Diaeetii 
acid. 

Ammonia, 
gins. 

Sugar, 
urine, 
gms. 

Carbo- 
hydrate 
balance, 
gms. 

Soda 
admin- 
istered. 

Weight 

IbB. 

Alveo- 
lar air, 
C02 
mm.  HK. 

1915. 

Dec.     0-  7 

3.31 

3.0% 

Shower* 

of  yranular  t 

asts. 

7-  S 

LSOO   '    Slight 

+  + 

3.9      ;     25 

-20 

0 

88 

20 

trace 

8-  9 

1200       Slight 

+  +  + 

2.G             7 

-7 

o 

88 

26 

j     trace 

9-10 

1200        Very 

+  + 

2.4 

2 

;^ 

0 

89 

29 

slight 

trace 

10-1  1 

1000     Slightest 

+  + 

2.9 

G 

—  I 

0 

89 

32 

possible 

trace 

11-12 

1400  ; 

+  + 

14 

16 

0 

88 

33 

12-13 

900     Slightest 

+  + 

1  .5 

9 

-9 

0 

89 

32 

possible 

trace 

Death 

in  coma,   Octob 

cr  20,  1910.2 

11.  Chlorides. — The  importance  of  a  knowledge  of  the  chlorides 
in  the  urine  is  due  to  the  remarkable  changes  of  weight  of  diabetic 
patients  which  are  apparently  related  to  the  excretion  and  retention 
of  sodium  chloride.  This  subject  is  discussed  under  Influence  of 
Sodium  Chloride  upon  the  Weight,  page  120. 

Volhard's  Quantitative  Method. — Solutions  required: 

1.  Silver  nitrate  solution:  29.06  grams  are  dissolved  in  1000  c.c. 
of  distilled  water.     One  cubic  centimeter  of  this  solution  is  equal  to 
0.01  gram  of  sodium  chloride. 

2.  Ammonium  sulphocyanate  solution:    Thirteen   grams  of  the 
chemically  pure  salt  are  dissolved  in  1000  c.c.  of  distilled  water. 
This  should,  however,  be  accurately  standardized  by  titration  with 
the  silver  nitrate  solution  so  that  1  c.c.  is  equal  to  1  c.c.  of  the 
silver  salt. 

3.  Indicator:    A  saturated  solution  of  ammonio-ferric  alum. 

4.  Concentrated  nitric  acid. 

5.  A  15  per  cent,  solution  of  potassium  permanganate. 

Ten  cubic  centimeters  of  the  urine  to  be  tested  are  pipetted  into  a 
100  c.c.  volumetric  flask.  Add  20  c.c.  of  the  standard  silver  nitrate 
solution,  about  5  c.c.  of  nitric  acid  and  5  c.c.  of  the  ammonio-ferric 
alum  solution.  If  this  mixture  is  dark  add  4  or  5  drops  of  the 
potassium  permanganate  solution,  when  the  mixture  will  become 
a  pale  yellow. 

1  Ammonia  in  14°  (!). 

2  For  continuation  of  case  see  Table  145. 


202       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

Now  add  distilled  water  to  the  100  e.c.  mark  and  then  shake  and 
filter  off  the  precipitated  siK'er  chloride.  Fifty  cubic  centimeters 
of  the  filtrate,  corresponding  to  5  c.c.  of  the  urine,  are  pipetted  into 
a  white  porcelain  dish  and  the  excess  of  silver  nitrate  is  determined 
by  titration  with  the  standard  ammonium  snlphocyanate  solution. 
The  end-point,  the  first  constant  reddish  color,  is  quite  definite. 

The  number  of  cubic  centimeters  of  ammonium  sulphocyanate 
solution  multiplied  by  2  and  subtracted  from  20  will  give  the 
number  of  cubic  centimeters  of  the  silver  salt  precipitated  by  the 
chlorides  in  10  c.c.  of  the  urine. 

The  method  can  be  .shortened  without  detriment  by  using  10  c.c. 
instead  of  20  c.c.  of  the  standard  silver  nitrate  solution  (adding  10 
c.c.  more  if  an  end-point  is  obtained  with  one  drop  of  standard 
ammonium  sulphocyanate).  Dilution  and  filtration  are  then 
unnecessary.  In  the  calculation  subtract  the  number  of  c.c.  of 
ammonium  sulphocyanate  used  from  10,  which  will  give  the  number 
of  cubic  centimeters  of  the  silver  salt  precipitated  by  the  chlorides 
in  10  c.c.  of  the  urine. 

This  number  divided  by  10  and  multiplied  by  0.01  and  by  the 
number  of  cubic  centimeters  of  urii.e  in  the  twenty-four-hour 
amount  gives  the  amount  of  chlorides  in  grams. 

B.  THE  EXAMINATION  OF  THE  BLOOD. 

The  blood  required  for  the  various  tests  which  follow  is  easily  and 
painlessly  obtained  if  a  22-gauge  needle  is  employed.  For  con- 
venience, during  the  last  few  months,  we  have  used  platinum 
needles.  These  can  readily  be  sterilized  and  sharpened.  The  total 
quantity  of  blood  required  seldom  exceeds  20  c.e.  and  generally  far 
less  because  it  is  rare  that  tests  are  necessary  for  acidosis.  For 
the  Benedict-Lewis  sugar  test  it  is  best  to  have  ">  c.c.  which  can  be 
transferred  to  a  flask  containing  a  few  crystals  of  potassium  oxalate; 
for  the  blood  fat  15  c.c.,  for  the  Van  Slyke  (X)o  test  (>  c.c.,  and  for 
the  "Wishart  acetone  test  4  c.c.  For  the  prevention  of  coagulation, 
as  a  routine,  at  the  Deaconess  Hospital,  we  are  accustomed  to  insert 
in  the  flask  three  drops  of  a  saturated  solution  of  sodium  citrate 
instead  of  a  few  crystals  of  potassium  oxalate,  and  to  moisten  the 
inside  of  the  20  c.c.  syringe  with  a  similar  quantity  of  the  citrate 
solution,  rinsing  out  the  syringe  thoroughly  therewith  and  expelling 
the  same  before  the  blood  is  drawn.  However,  it  this  method  is 
adopted  the  blood  should  be  shaken  vigorously  for  three  minutes 
(by  the  watch)  after  it  has  hem  transferred  to  the  flask.  This 
would  be  objectionable  in  the  case  of  blood  drawn  for  the  Van  Slyke 
('()-.>  test,  and  in  that  case  a  few  crystals  of  potassium  oxalate  should 
be  employed. 


EXAMIXATION  OF  THE  BLOOD  203 

1.  Blood  Sugar. — (a)  Lewis-Benedict  Method.1 — At  the  present 
time  this  method  appears  to  be  the  one  in  most  general  use  and  the 
method  which  gives  the  most  reliable  results.  The  color  obtained 
by  heating  a  dextrose  solution  with  picric  acid  and  sodium  car- 
bonate is  employed  as  the  basis  of  the  method  proposed  by  Lewis 
and  Benedict  for  the  determination  of  blood  sugar.  The  blood 
protein  is  removed  by  precipitation  with  picric  acid.  The  method 
of  blood-sugar  determination  is  as  follows:  Two  c.c.  of  blood,  and 
more  if  other  blood  tests  are  desired,  are  collected  in  a  small  flask 
containing  one  or  two  crystals  of  potassium  oxalate.  For  the  test  2 
c.c.  of  blood  should  be  transferred  at  once  into  a  25  c.c.  volumetric 
flask  containing  5  c.c.  of  water.  The  contents  of  the  flask  are  shaken 
to  insure  thorough  mixing  and  the  consequent  hemolysis  of  the 
blood.  Then  15  c.c.  of  saturated  aqueous  solution  of  picric  acid 
are  added,  as  well  as  a  drop  or  two  of  alcohol  to  dispel  any  foam, 
and  the  contents  of  the  flask  are  made  up  to  the  mark  with  water 
and  then  shaken.  After  filtration  8  c.c.  aliquots  are  measured 
out  into  large  Jena  test-tubes  for  duplicate  determinations.  Two 
c.c.  of  saturated  picric  acid  solution  and  exactly  1  c.c.  of  10  per 
cent,  sodium  carbonate  are  added  (as  well  as  two  glass  beads  and 
two  or  three,  or  even  five  to  ten  drops  of  mineral  oil)  and  the 
contents  of  the  tubes  are  evaporated  rapidly  over  a  direct  flame 
until  precipitation  occurs.  About  3  c.c.  of  water  are  added,  the 
tube  is  again  heated  to  boiling  to  dissolve  the  precipitate,  the 
contents  of  the  tube  are  transferred  quantitatively  to  a  10  c.c. 
volumetric  flask,  cooled,  made  up  to  the  mark,  shaken,  and  then 
filtered  through  cotton  into  the  colorimeter  chamber.  The  color 
is  compared  at  once  with  that  obtained  from  0.65  ing.  of  anhy- 
drous dextrose,  5  c.c.  of  saturated  picric  acid,  and  1  c.c.  of  10  per 
cent,  sodium  carbonate  when  evaporated  to  precipitation  over  a 
free  flame  with  beads  and  oil  and  diluted  to  10  c.c.  The  calculation 
of  the  sugar  present  in  the  unknown  blood  sample  is  very  simple. 
The  original  2  c.c.  of  blood  were  diluted  to  25  c.c.,  and  of  this 
amount  8  c.c.  were  taken  for  a  determination.  In  other  words, 
the  aliquot  contained  the  equivalent  of  -^  x  2  c.c.,  or  0.04  c.c.  of 
blood.  A  permanent  standard  can  be  made  by  dissolving  picramic 
acid  in  an  aqueous  solution  of  sodium  carbonate.  For  details,  see 
original  article. 

At  the  Deaconess  Hospital  the  Lewis-Benedict  tests  are  performed 
in  a  manner  slightly  different  from  the  Lewis-Benedict  method  as 
described  above,  but  in  general  according  to  the  modification  of 
Myers  and  Bailey. - 

Place  0.5  to  1  gram  picric  acid  in  a  25  c.c.  volumetric  flask,  add 

1  Lewis-Benedict :    Jour.  Hiol.  Choni.,  1915,  xx.  p.  01. 

2  Myers  and  Bailey:  Jour.  Biol.  Choin.,  1910,  xxiv,  p.  147. 


204       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

5  c.c.  blood,  dilute  to  25  c.c.  with  distilled  water  and  shake  until 
the  complete  disappearance  of  the  red  color.  Centrifugalize,  then 
filter  the  supernatant  liquid,  take  -'>  c.c.  of  the  filtrate,  measured 
accurately  with  pipette,  put  in  10  c.c.  volumetric  flask  and  to  this 
add  1  c.c.  of  a  20  per  cent,  solution  sodium  carbonate  (2!>.4  per 
cent,  solution  of  monohydrated  sodium  carbonate).  Heat  on  the 
water-bath  for  fifteen  minutes.  Allow  to  cool,  make  up  to  10  c.c. 
with  distilled  water  and  read  against  the  standard  picramic  acid  in 
the  colorimeter. 

(b)  Bang's  Method.1 — The  test  depends  on  the  assumption  that 
copper  is  reduced  by  sugar  without  regard  for  the  amounts 
present.  In  other  words,  a  sugar  solution  from  100  mg.  of  blood 
will  reduce  as  much  copper  proportionately  as  a  solution  from  100 
c.c.  of  blood.  If  the  microscopic  amount  of  copper  involved  in 
the  reaction  can  be  determined  the  results  will  be  as  accurate  as 
if  larger  amounts  of  the  metal  are  used.  Accordingly  an  albumin- 
free  sugar  solution  is  made  from  a  small  amount  of  blood  and  is 
boiled  with  copper  solution.  The  cuprous  oxide  which  is  formed  is 
held  in  solution  by  the  method  which  Bang  has  described  previously 
and  is  reoxidized  by  iodine  in  the  presence  of  potassium  carbonate. 
Cupi-ic  carbonate  and  potassium  bicarbonate  are  formed  while 
potassium  iodide  is  set  free  and  can  be  tested  for  with  starch  as 
an  indicator.  The  reaction  is  quantitative  and  extremely  delicate. 
The  technic  for  the  test  is  given  in  detail  by  Fitz,2  from  whom  I 
quote  freely. 

The  copper  solution  is  made  by  dissolving  100  grams  of  potassium 
bicarbonate  in  from  600  to  700  c.c.  of  distilled  water.  100  grams  of 
potassium  carbonate  are  added,  (>(>  grams  of  potassium  chloride  and 
100  c.c.  of  a  4.4  per  cent,  copper  sulphate  solution  (C\iS()4  +  51 12O). 
When  everything  is  dissolved  the  mixture  is  diluted  to  1  liter  and 
is  ready  for  use  after  it  is  allowed  to  stand  for  twenty-four  hours. 

Titration  is  made  with  two-hundredth-normal  iodine  solution 
prepared  from  1  c.c.  of  2  per  cent,  potassium  iodate  solution,  2 
grams  of  potassium  iodide  and  5  c.c.  of  tenth-normal  hydro- 
chloric acid,  the  mixture  being  diluted  to  100  c.c.  This  solution  is 
unstable  and  must  be  renewed  every  three  or  four  days. 

Two  or  three  drops  of  blood  are  placed  on  a  small  piece  of  thick 
blotting  paper,3  which  previously  has  been  boiled  in  dilute  acetic 
acid  and  water  to  remove  traces  of  albumin  and  sugar.  The  blot- 
ting paper  should  be  cut  in  oblongs  10  to  20  mm.  and  weighed 
before  and  after  the  blood  is  added.  In  this  way  the  weight  of 
blood  to  within  1  mg.  is  found.  In  these  experiments  small  weigh- 

1  HaiiK:    Dcr  Blut/ucker,  Wiesbaden,  I'U.'i. 

2  Fitz:  Arch.  Int.  Mod.,  i!)M,  xiv,  p.   IM. 

5  \Yo  have  used  filter  paper  (No.  /is'.),  7  cm.  dia.),  purchased  from  Kimer  &  Amend, 
New  York. 


EXAMINATION  OF  THE  BLOOD  205 

ing  flasks  were  used  to  hold  the  blood  and  paper.  After  the  blood 
is  weighed  the  protein  is  precipitated  by  hydrochloric  acid  in  potas- 
sium chloride.  For  this  purpose  1360  c.c.  of  saturated  potassium 
chloride  are  diluted  with  640  c.c.  of  distilled  water  and  1.5  c.c.  of 
25  per  cent,  hydrochloric  acid  is  added.  Of  this  mixture  6.5  c.c. 
are  used  for  the  precipitation  and  added  boiling  hot;  6.5  c.c.  are 
also  added  to  wash  the  solution  into  the  boiling  flask. 

The  albumin  in  the  blood  precipitates  on  the  blotter,  while  the 
sugar  diffuses  through  the  solution.  After  half  an  hour's  cooling 
the  sugar  solution  is  transferred  to  a  50  c.c.  Jena  flask  with  a 
straight  neck  and  is  washed  in  by  6.5  c.c.  potassium  chloride  solu- 
tion. In  this  way  all  the  sugar  in  the  blood  is  removed  from  the 
weighing  flask  and  is  ready  for  titration.  One  cubic  centimeter  of 
the  copper  solution  is  now  added  and  the  mixture  is  boiled  over  a 
micro-burner.  The  heating  is  an  important  factor  in  the  test. 
The  solution  must  be  warmed  so  that  it  begins  to  boil  in  between 
one  minute  and  fifteen  seconds  and  one  minute  and  a  half,  and  must 
be  boiled  for  exactly  two  minutes,  since  the  copper  solution  can  be 
reduced  by  longer  or  more  vigorous  boiling  and  will  give  improper 
readings.  At  the  end  of  this  time  the  flask  is  immersed  in  cold 
water  and  titrated. 

A  source  of  error  in  the  determination  is  air  oxidation  of  the 
reduced  copper.  During  boiling  this  is  discounted.  But  after 
cooling,  air  must  be  kept  out  of  the  solution  by  manipulating  it 
under  carbon  dioxide  gas.  For  this  purpose  Bang  introduced  into 
the  neck  of  the  flask  a  hooked  glass  tube  which  was  connected 
to  a  carbon  dioxide  tank.  The  gas  was  turned  on  as  soon  as  the 
flask  was  put  into  cold  water  and  in  this  way  air  oxidation  was 
prevented.  Thannhauser  and  Pfitzer1  used  small  flasks  with  side- 
arms  which  were  easier  to  handle.  Similar  flasks  were  used  in  our 
experiments. 

After  the  two  minutes'  boiling  the  gas  is  introduced  and  the  flask 
is  immediately  cooled.  This  can  be  done  in  less  than  three  seconds. 
A  few  drops  of  1  or  2  per  cent,  soluble  starch  solution  are  now  added 
as  an  indicator.  The  titration  is  made  from  a  1  or  2  c.c.  differential 
pipette  reading  in  hundredths  of  a  cubic  centimeter,  and  the  iodine 
solution  is  added  until  the  light  blue  color  of  the  copper  solution 
takes  on  the  deep  blue  color  of  the  starch  and  iodide. 

Bang  has  tested  the  method  carefully  with  known  sugar  solutions. 
The  amount  of  iodine  used  by  increasing  amounts  of  sugar  is  so 
nearly  constant  that  he  has  been  able  to  make  a  formula  for  deter- 
mining the  amount  of  sugar  present.  The  amount  of  iodine  used 
in  titration  is  divided  by  2.2.  This  result  minus  0.01  will  give  the 

1  Thannhauser  and  Pfitzer:  Munch,  rned.  "Wchnschr.,  1913,  Ix,  p.  2155. 


200        ritl.\K,    BLOOD  AND   RESPIItATIOX   IX    DIABETES 

milligrams  of  sugar  present  in  the  solution.  In  these  experiments  a 
special  table  was  constructed,  however,  which  showed  the  iodine 
readings  for  varying  amounts  of  sugar  from  which  the  blood-sugar 
readings  per  100  c.c.  of  blood  were  calculated. 

The  entire  test  takes  less  than  three-quarters  of  an  hour,  requires 
so  little  blood  that  it  can  be  repeated  on  the  same  individual  at 
will,  and  is  fairly  easy  to  perform  after  short  practice. 

Comparative  experiments  show  that  the  results  obtained  by  the 
micro  method  were  not  absolutely  accurate  if  the  results  obtained 
by  the  Bertram!  method  are  considered  correct.  In  a  series  of 
forty-two  determinations  by  both  methods,  however,  Fit/  found  in 
only  '2  cases  a  difference  of  more'  than  0.0.' 5  gram  per  100  c.c.  of 
blood.  This  means  that  while  the  absolute  error  was  large  the 
relative  error  was  slight.  The  curve  of  blood-sugar  determinations 
made  from  all  the  examinations  was  closely  parallel.  Hence,  for 
comparative  and  repeated  studies  in  blood-sugar  estimations  the 
micro  method  is  excellent.  Furthermore,  since  the  amount  of 
blood  required  to  make  the  test  is  so  small  and  the  technic  so  simple 
the  method  affords  an  excellent  clinical  means  for  the  estimation  of 
blood  sugar.1 

(<•)  Other  Methods. — Epstein2  has  devised  a  .simple  procedure  for 
the  estimation  of  blood  sugar  requiring  but  a  few  drops  of  blood, 
and  of  this  1  hear  favorable  reports. 

Strouse:!  has  called  attention  to  the  advantages  of  the  Kowarsky 
method,  which  also  requires  but  little  blood  and  demands  but 
little  time. 

2.  Lipoids. — The  frontispiece  is  sufficient  evidence  of  the  desir- 
ability of  examining  the  blood  of  diabetic  patients  for  its  content  of 
lipoids.  It  is  true,  one  seldom  sees  cases  with  so  high  (0.4)  a  per 
cent,  of  blood  fat  as  Case  Xo.  7S(>,  and  in  fact,  I  have  had  no  other 
among  l!S  cases  for  whom  analyses  have  been  made  in  Prof. 
Bloor's  laboratory.1  One  reason  for  this  is  that  less  fat  is  given 
now  than  formerly  and  another  that  the  blood  is  examined  for 
the  lipoids  before  instead  of  after  a  meal.  Notwithstanding  these 
changed  conditions,  however,  the  lipoids  have  been  almost  invari- 
ably increased  in  diabetic  patients  either  as  a  whole  or  in  part  (as 
fatty  acids,  cholesterol,  lecithin).  Of  the  cases  examined,  an  in- 

1  Whereas  this  method  is  adinir:il>li<  in  the  hands  of  skilled  laboratory  workers, 
il  is  not  practicable  for  others.  It,  has  been  used  for  a  ye:ir  and  a  half  with  success 
by  I'..  II.  liable  in  my  laboratory  and  by  Miss  Habcock  at,  1  lie  Nutrition  Laboratory, 
by  whom  all  blood-sunar  analyses  report  eel  in  the  first  edition  of  this  book  were 
made  s:ive  seven  by  II.  Koefod,  who  is  also  -killed  in  the  technic.  Since  the 
early  months  of  I'.IUi  the  Meyers  and  liailey  modification  of  the  Lewis-Benedict 
method  has  been  exclusively  employed 'and  with  far  greater  satisfaction. 

-  Kp.-tein:  Jour.  Am.  Mod.  Assn.,  I'.UI.  Ixiii,  p.   Hid?. 

3  St  rouse -.Johns  Hopkins  IIosp.  Hull.,  P.M."),  xxvi,  p.  i'1-l. 

1  In  :i  subsequent  .-'erics  of  KU  specimen-:  of  blood,  representing  X7  of  my  cases, 
examined  by  Horace  Gray,  no  value  above  this  was  obtained,  save  in  Case  Xo.  "Mi, 
who  on  one  occasion  showed  !<>.:}  per  cent  .and  on  another  11.1  per  cent,  total  lipoids. 


EXAMIXATIOX-   OF  THE  BLOOD  207 

crease  was  found  in  20,  a  normal  state  in  2,  and  a  decrease  in  none. 
The  blood  fat  should  be  normal  in  all  cases  of  diabetes  and  no  case 
of  diabetes  should  be  considered  cured  otherwise.  When  carbohy- 
drate and  protein  are  unassimilated,  they  appear  in  the  urine,  but 
when  fat  fails  of  assimilation,  it  collects  in  the  blood. 

The  normal  variations  of  the  lipoids  in  the  blood  and  the  changes 
which  they  undergo  have  been  described  on  page  102. 

The  method  given  below  for  the  estimation  of  the  blood  lipoids  is 
that  now  employed  by  Professor  Bloor,  and  kindly  given  me  by  him. 
It  is  a  modification  of  his  method  published  in  1914, !  and  of  that  in 
the  first  edition  of  this  book. 

"The  method  to  be  described  depends  on  a  new  principle — the 
determination  of  the  fat  by  precipitation  in  a  water  solution  and 
comparison  of  the  cloudy  suspension  so  obtained  with  that  of  a 
similarly  prepared  standard  fat  solution  by  the  use  of  the  nephel- 
ometer.  The  determination  may  be  completed  in  about  three- 
quarters  of  an  hour  and  may  be  carried  out  with  from  O.o  c.c.  to 
5  c.c.  of  blood.  Ordinarily  about  2  c.c.  are  used.  It  has  been 
found  to  be  accurate  to  within  5  per  cent,  of  the  total  fat.  The 
procedure  is  as  follows : 

"Extraction. — Three  c.c.  of  freshly  drawn  and  well-mixed  blood 
are  run  in  a  slow  stream  of  drops  into  a  graduated  flask  containing 
about  80  c.c.  of  a  mixture  of  3  parts  alcohol  and  1  part  ether  (both 
redistilled),  which  is  kept  in  constant  motion  by  rotating  the  flask. 
The  solution  is  raised  to  boiling  by  immersion  in  a  water-bath  (with 
frequent  shaking  to  prevent  superheating),  cooled  to  room  tempera- 
ture, made  up  to  volume  with  alcohol-ether,  mixed  and  filtered. 
The  extract  if  placed  in  tightly  stoppered  bottles  in  the  dark  will 
keep  several  months  unchanged. 

''Determination. — From  5  to  20  c.c.  (ordinarily  10  c.c.)  of  the 
extract,  containing  about  2  nig.  of  'fat,'  are  measured  with  a 
pipette  into  a  small  beaker  and  saponified  by  evaporating  just  to 
dryness  with  2  c.c.  of  y  sodium  ethylate  (made  by  dissolving 
cleaned  metallic  sodium  in  absolute  alcohol).  After  evaporation 
is  complete  5  c.c.  of  alcohol-ether  are  added  and  the  mixture  heated 
slowly  to  boiling.  A  similar  solution  of  the  standard  is  prepared 
by  measuring  5  c.c.  of  the  standard  fat  solution  (see  below)  into  a 
beaker  and  heating  to  boiling  as  above.  Fifty  c.c.  of  distilled  water 
are  now  added  to  each  beaker  and  the  solutions  mixed  by  stirring, 
taking  care  that  all  the  material  in  the  saponifieation  beaker  is 
dissolved.  To  standard  and  test  solutions  are  added,  as  nearly 
simultaneously  as  possible,  10  c.c.  portions  of  dilute  (1  to  4)  hydro- 
chloric acid  and  the  solutions  allowed  to  stand  five  minutes,  after 
which  they  are  transferred  to  the  comparison  tubes  of  the  nephel- 
ometer. 

1  Bloor:  Jour.  Biol.  Chem.,  1914,  xvii,  p.  37b. 


208       I'RINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

"If  bubbles  appear  on  the  walls  of  the  tubes  they  should  be  removed 
by  inverting  the  tubes  two  or  three  times.  The  movable  jacket 
ou  the  standard  tube  is  set  at  a  convenient  point,  generally  50  nun. 
(Richard's  nephelometer)  and  comparisons  made  by  adjusting  the 
jacket  on  the  test  solution  until  the  images  of  the  two  solutions 
show  equal  illumination.  Not  less  than  five  readings  are  taken, 
alternately  from  above  and  below,  and  the  average  taken  as  the 
correct  reading. 

"The  standard  solution  used  is  an  alcohol-ether  solution  of  pure 
triolein  of  which  5  c.c.  contain  about  2  ing.  of  fat.  The  alcohol 
and  ether  used  for  the  .standard  are  freshly  redistilled  absolute 
alcohol  and  pure  dry  ether." 

'.}.  Non-protein  Nitrogen. — During  the  last  year  the  determina- 
tion of  the  non-protein  nitrogen  in  the  blood  of  many  of  my  diabetic 
patients  had  been  made  by  my  assistant,  Dr.  W.  Richard  Ohler. 
The  results  of  these  and  other  tests  of  renal  function  will  eventually 
be  published  elsewhere,  but  the  facts  here  presented  will  give  an 
indication  of  what  has  been  found  to  date.  The  remarkable  effi- 
ciency of  the  kidneys  of  patients  with  diabetes  has  always  impressed 
me,  and  the  onset  of  renal  disease  in  cases  of  diabetes  of  long  dura- 
tion has  been  far  less  frequent  than  most  of  us  would  anticipate. 
Proof  of  this  is  shown  by  the  moderate  changes  of  blood-pressure  in 
cases  of  diabetes  over  long  periods  of  time.  (See  p.  414.)  On  the 
other  hand,  in  beginning  coma  renal  involvement  has  always  seemed 
to  me  to  be  marked.  Today  the  question  arises  as  to  whether  this 
may  not  have  been  in  part  due  to  the  alkaline  treatment  at  such 
times,  which  forced  an  excessive  quantity  of  acid  through  the  kid- 
neys. The  evidence  collected  by  Dr.  Ohler  will  help  in  the  study 
of  renal  involvement  in  diabetes,  but  as  yet  the  data  are  not  sufficient 
to  allow  decisive  statements  to  be  made.  Particularly  do  I  wish 
to  be  conservative  because  Dr.  Reginald  Fit/,  1  understand,  has 
worked  assiduously  upon  this  problem  during  the  last  year  at  the 
Rockefeller  Institute,  and  with  his  own  experience  with  cases  of 
renal  disease  in  Christian's  clinic  at  the  Peter  Bent  Brigham  Hos- 
pital, his  conclusions  must  have  great  weight. 

The  non-protein  nitrogen  of  the  blood  varies  in  normal  individuals 
between  20  and  I50  mg.  per  100  c.c.  blood.  In  this  series  of  :>0 
cases  and  :'>(>  determinations,  Dr.  Ohler  found  the  non-protein 
nitrogen  to  be  normal  in  M4  per  cent.,  increased  in  (>0  per  cent,  and 
decreased  in  (>  per  cent.  Should  20  to  -10  mg.  per  100  c.c.  blood  be 
taken  as  normal  for  the  non-protein  nitrogen,  (IS  per  cent,  of  the 
observations  would  come  within  this  group. 

Two  casc-s  showed  a  non-protein  nitrogen  of  1(1  and  20  ing. 
From  Table  100  it  will  be  seen  that  these  are  young  individuals  with 
normal  blood-pressure  and  no  evidence  of  disturbance  of  renal 


EXAMINATION  OF  THE  BLOOD 


209 


II 


14 


210       1'lfIXK,   BLOOD  AM)  RESPIRATION  IX   DIAMETER 

function,  for  albumin  and  casts  arc  absent  from  the  urine  and  the 
excretion  of  plieuolphtlialein  in  one  case  was  5S  per  cent,  in  t\vo 
hours.  It  is  noticeable  that  these  low  values  were  in  association 
with  the  normal  blood-pressure  in  one  instance  and  a  blood  sugar 
of  ().f)7  percent,  in  another,  plainly  showing  the  independence  of  the 
non-protein  nitrogen  in  the  blood  and  the  blood  sugar.  The  low 
values  might  well  be  accounted  for  by  the  fact  that  one  of  the 
patients  had  been  without  protein  in  the  diet  for  four  days  and  the 
other  for  one  day. 

In  the  second  group  of  cases,  with  the  non-protein  nitrogen  vary- 
ing between  121  and  )•>()  ing.,  all  but  two — Cases  Xos.  107(>  and 
1104  stand  in  agreement  with  the  normal  phenolphthalein  excre- 
tion. Both  of  these  cases  were  on  a  comparatively  low  protein 
diet,  and  this  may  account  for  the  fact  that  the  non-protein  nitrogen 
is  within  normal  linits  while  the  phenolphthalein  was  respectively 
28  and  ',}()  per  cent.  In  each  case  the  blood-pressure  was  increased. 
It  is  quite  likely  that  another  case  Xo.  1197  might  have  shown  a 
low  phenolphthalein  output,  and  it  is  unfortunate  that  such  a  test 
had  not  been  made,  for  albumin,  casts  and  a  high  blood-pressure 
we're  noted  in  this  patient.  Xo  particular  relation  is  evident 
between  the  non-protein  nitrogen  and  the  evidences  of  acidosis,  and 
absolutely  no  relation  between  the  non-protein  nitrogen  and  the  sugar 
in  the  blood.  In  the  group  is  included  Case  Xo.  lOoo,  with  a  non- 
protein  nitrogen  of  27.")  nig.,  marked  acidosis  and  evidences  of 
renal  involvement  but  he  received  only  13  grams  of  protein,  in  the 
preceding  six  days.  Unfortunately  no  phthalein  test  was  done. 
Had  the  protein  been  greater  in  the  diet,  it  is  quite  probable  that 
the  non-protein  nitrogen  would  have  been  increased  in  the  blood. 
The  influence  of  fasting  on  non-protein  nitrogen,  therefore,  is  by 
no  means  to  be  disregarded  as  a  therapeutic  means  of  treatment. 

The  independence  of  the  blood  sugar  of  the  non-protein  nitrogen 
is  again  apparent. 

(Iroup  III  represents  those  patients  whose  non-protein  nitrogen 
was  on  the  border-line  of  normal—  namely,  between  o2  and  K) 
mg.  The  average  age  of  the  patients  in  this  group  is  but  two 
years  more  than  in  (Jroup  I,  so  that,  age  cannot  be  influential 
in  causing  the  increase.  'That  the  renal  involvement  was  con- 
siderable!, the  presence  of  albumin  in  10  out.  of  !•>  cases  and  of 
casts  in  7  cases  bear  \vitness.  The  phenolphthalein  excretion 
was  In'low  normal  in  I  of  the  <>  cases  tested,  and  in  7  of  the  11 
cases  the  blood-pressure  was  increased.  The  volume  of  the  urine 
was  increased  in  .">  of  the  !>  cases  in  which  the  twenty-four  hour 
quantity  was  known  for  the  day  of  the  test.  The  blood-sugar 
was  distinctly  elevated.  (  lear  evidence  of  renal  involvement  is 
therefore  manifest  in  these  patients,  and  the  non-protein  nitrogen 


EXAMINATION  OF   THE  BLOOD  211 

is  an  expression  of  it.  This  cannot  be  ascribed  to  the  diet,  for  that 
was  low  in  protein  in  practically  all  the  cases.  Is  the  renal  involve- 
ment primary  or  secondary'/  In  answer  to  this  question  the  dura- 
tion of  the  disease  is  certainly  important.  Whereas  this  was  1.5 
years  in  Group  I,  it  was  6.7  years  in  Group  II  and  3.4  years  in 
Group  III. 

The  intensity  of  the  dialxrtes  was  greater,  as  shown  by  the  greater 
frequency  of  acidosis  and  the  higher  percentage  of  sugar  in  the 
blood.  Therefore,  so  far  as  this  group  is  concerned,  the  intensity  of 
the  diabetes  appears  to  have  affected  the  kidneys  unfavorably. 
The  values  for  ( 'ase  Xo.  10SO,  following  an  operation  for  removal  of 
the  prostate,  are  interesting  in  comparison  with  the  values  for  the 
same  patient  shown  in  Group  IV,  which  were  nearly  twice  as  high, 
having  been  obtained  Ixrfore  the  operation. 

Group  IV  comprises  cases  of  diabetes  who  showed  a  non-protein 
nitrogen  of  40  nig.  or  over.  All  of  these  patients  exhibited  albumin- 
uria,  and  the  phenolphthalein  excretion  was  decrease,!  in  the  4  cases 
in  which  it  was  tried.  The  protein  in  the  diet  was  generally  low. 
Acidosis  was  present  in  most  of  the  cases.  Two  of  the  higher  values 
were  for  the  prostatic  case,  Xo.  1086,  after  his  bladder  had  been 
drained,  but  before  the  prostate  was  removed.  The  lower  value, 
58  mg.,  was  obtained  eleven  days  after  the  drainage  of  the  bladder 
by  Dr.  Chute;  the  higher  value,  70  mg.,  four  days  after  the  drainage. 
Case  Xb.  1 190  was  a  very  severe  diabetic  with  marked  inanition ;  it  is 
notable  that  a  lower  value  (see  Group  III)  was  obtained  soon  after 
entrance,  when  he  showed  acidosis.  For  a  presentation  of  all  the 
data  relating  to  this  case  see  page  379.  Case  Xo.  1143,  with  the 
highest  value  of  all,  died  in  coma.  The  blood  was  taken  immediately 
thereafter.  Whether  the  latter  circumstance  had  influenced  the 
proportion  of  non-protein  nitrogen  in  the  blood  I  do  not  know. 
The  test  must  be  performed  in  other  cases  of  coma  to  settle  the 
influence  of  this  factor. 

(a)  Determination  of  Non-protein  Nitrogen  in  Blood  by  Titration. — 
The  method  employed  is  in  general  the  same  as  the  method  used 
by  Folin  and  Denis.1 

Five  cubic  centimeters  of  well-mixed  blood  are  run  into  a  50  c.c. 
measuring  flask  half-filled  with  acetone-free  methyl  alcohol.  The 
flask  is  now  filled  up  to  the  mark  with  methyl  alcohol  and  vigorously 
shaken. 

After  two  or  more  hours  the  contents  of  the  flasks  are  filtered 
through  hard,  dry  filters.  To  the  slightly  colored  filtrate  are  then 
added  two  or  three  drops  of  a  saturated  alcoholic  solution  of  zinc 
chloride  and  after  standing  but  a  few  minutes  the  mixture  is  filtered 

1  Folin  and  Denis:    Jour.  Biol.  Chcm.,  1912,  xi,  p.  527. 


•212        I'KIXE,   BLOOD   AND   KEXP1RA  TI().\   IX   DIABETES 

through  a  dry  filter  paper.  The  filtrate  should  now  be  perfectly 
colorless. 

Ten  cubic  centimeters  of  this  filtrate  are  now  pipetted  into  a  tube 
of  the  same  kind  as  is  used  in  urine  analysis.  One  drop  of  sulphuric 
acid  and  a  glass  bead  or  pebble  is  added  and  the  methyl  alcohol 
driven  off  by  immersing  the  tube  in  a  beaker  of  boiling  water  or  by 
gently  heating  over  a  free  flame.  After  the  alcohol  is  removed 
digestion  is  carried  out  just  as  in  the  case  of  urine.1 

One  cubic  centimeter  of  sulphuric  add,  1  gram  of  potassium 
sulphate,  and  a  drop  or  two  of  10  per  cent,  copper  sulphate  are 
added. 

When  digestion  is  complete,  and  the  digestion  mixture  has  cooled 
until  viscous,  8  to  lOc.c.  of  distilled  water,  a  drop  of  ali/arin  indi- 
cator, and  a  pinch  of  talcum  are  added,  and  the  tube  transferred 
to  the  distillation  rack  where,  after  neutralizing  with  sodium 
hydroxide,  as  in  the  case  of  urine,  the  ammonia  is  driven  over  into 
10  c.c.  of  ~7N0-  hydrochloric  acid. 

The  10  c.c.  of  filtrate  used  arc  equal  to  '2  c.c.  of  the  blood.  The 
calculation  after  titrating  the  excess  acid  with  7X0-  sodium  hydroxide 
is  as  follows: 

X  X  0.0002  >;    100 

=    grams    of    non-protein    nitrogen    in    100 

grams  of  blood,  X  being  the  number  of  cubic  centimeters  of  acid 
neutralized  by  the  ammonia  by  distillation. 

One  cubic  centimeter  of  the1  -7X()-  acid  is  equal  to  0.0002  gram 
nitrogen.  The  calculation  is  made  in  terms  of  100  c.c.  of  blood  for 
the  sake  of  convenience. 

4.  Chlorides. — The  determination  of  the  chlorides  in  the  blood 
gains  importance  from  the  fact  that  the  water  content  of  the  body 
in  diabetes  varies  so  rapidly  and  to  so  great  an  extent.  As  yet 
few  data  have  been  published  upon  this  point,  but  I  insert  the 
test  recently  described  by  McLean  and  Van  Slyke-  because  of  the 
increasing  importance  of  the  subject.  The  determination  requires 
two  steps:  (1)  Removal  of  proteins;  ("2)  titration  of  chlorides. 
Two  cubic  centimeters  of  oxalated  plasma,  with  the  aid  of  an  accu- 
rately calibrated  or  Ostwald  pipette,  are  run  into  a  20  c.c.  stoppered 
volumetric  flask  which  contains  10  c.c.  of  a  10  per  cent,  magnesium 
sulphate  solution.  The  pipette  is  rinsed  twice  by  drawing  up  into 
it  the  solution  from  the  flask.  Two  drops  of  ~>0-per  cent,  acetic  acid 
are  added.  The  flask  is  filled  to  the  mark  with  water,  the  contents 

1  In  private  pract  ice  or  in  hospital  wards  where  ii    would  be  bothersome  to  carry 
flasks,  pipettes  and  methyl  aleohn],   10  or  more  c.c.  of  blood  may  be  drawn  from  the 
vein  into  an  open-mouth  bottle  containing  about   0.1   Kram  of  powdered  potassium 
oxalate  to  prevent,  clot  tins:. 

2  McLean  and  Van  Slyke:    Jour.  Biol.  Thorn. .  101.-),  xxi,  p.  'Ml. 


EXAMIXATION  OF  THE  BLOOD  213 

mixed  by  inverting  the  flask,  and  then  heated  in  a  bath  to  100°  C.  for 
ten  minutes.  By  keeping  the  stopper  loosely  in  place  evaporation 
is  prevented,  and  when  cool  the  contents  return  to  their  original 
volume.  A  shorter  period  of  heating  than  ten  minutes  may  give 
lo\v  values  in  the  filtrate.  The  flask  is  then  allowed  to  cool  and  the 
contents  are  poured  into  about  0.3  gram  of  Merck's  "  blood-charcoal 
reagent."  After  a  few  minutes  the  liquid  is  filtered  through  a  dry 
filter  and  a  water-clear  filtrate  obtained.  Occasionally  a  small 
amount  of  charcoal  passes  through  with  the  first  few  drops  of  filtrate, 
but  this  can  be  poured  back  through  the  same  filter,  and  the  filtrate 
then  obtained  is  absolutely  clear  and  colorless. 

Ten  cubic  centimeters  of  this  filtrate  are  transferred,  by  means  of 
an  Ostwald  pipette,  to  a  25  c.c.  volumetric,  flask,  5  c.c.  of  solution 
I1  are  added,  and  the  whole  is  made  up  to  the  25  c.c.  mark  with 
distilled  water.  Five  cubic  centimeters  of  solution  1  will  precipitate 
up  to  10  mg.  of  XaCl.  In  samples  with  high  percentage  of  chloride 
only  enough  filtrate  is  taken  to  keep  within  this  limit  of  10  mg. 
Two  drops  of  cotyl  (caprylic)  alcohol  are  added,  and  the  vessel  is 
stoppered  and  shaken  gently  by  inverting  it  several  times. 
Immediate  coagulation  of  the  protein  occurs.  After  allowing  five 
minutes  for  complete  precipitation  to  take  place  the  solution  is 
filtered  through  a  dry  filter  and  a  perfectly  clear  and  colorless 
filtrate  is  again  obtained. 

An  aliquot  part  of  the  filtrate,  preferably  20  c.c.,  is  used  for  titra- 
tion.  Thus  one  has  in  this  20  c.c.  of  filtrate  the  equivalent  of  4  c.c. 
of  solution  1 ,  and  accordingly  4  c.c.  of  solution  3-  must  be  added. 

The  starch  is  first  dissolved  by  the  aid  of  heat  in  500  c.c.  of  water, 
the  citrate  and  nitrite  then  added,  and  the  whole  filtered  through 
cotton;  the  filter  washed  with  hot  water,  the  filtrate  allowed  to 
cool  and  made  up  to  1000  c.c.  The  solution  becomes  a  little  cloudy 
upon  standing,  but  its  efficacy  is  unimpaired,  and  this  slight 
turbidity  in  no  way  interferes  with  the  end-point. 

Solution  2  (KI,  3  grams;  water,  1000  c.c.)  contains  M/5S.5 
potassium  iodide,  1  c.c.  of  which  is  equivalent  to  1  mg.  of  XaCl. 

The  solution  is  standardized  against  the  silver  solution  by  adding 
5  c.c.  of  the  latter  to  5  c.c.  of  solution  3  and  titrating  with  the 

1  Solution  1  is  an  acid  M  29.2.3  solution  of  silver  nitrate,  1  c.c.  of  which  is  equiva- 
lent to  2  mg.  of  XaCl. 

AgXOs 5.812  grains 

HXOs 2.-)0.0       c.c. 

Water  to 1000.0       c.c. 

"  Solution  :i  contains  substances  which  respectively  regulate  the  acidity,  provide 
an  oxidizing  agent  for  the  iodide,  and  serve  as  indicator: 

Sodium  citrate  (NasCeNjOr  +  5J  N2O)        .      .      .        440.0  grams 

Sodium  nitrite 20.0  grams 

Soluble  starch 2.5  grams 

Water  to  1000.0  c.c. 


214       URINE,   BLOOD   AXD   RESPIRATION  IN   DIABETES 

iodide  solution  to  the  blue  end-point.  The  iodide  solution  is  then 
diluted  to  such  a  decree  that  10  c.c.  are  exactly  equivalent  to  5  c.c. 
of  the  silver  solution.  Potassium  iodide  is  run  in  from  a  burette 
until  the  blue  end-point  appears.  The  first  definite  blue  color  is 
taken  as  the  end-point,  and  with  slight  practice  is  unmistakable. 

The  result  may  be  calculated  from  the  following  formula,  which 
applies  when  20  c.c.  of  the  filtrate  from  silver  chloride  are  titrated: 

12. 5  (8  c.c.  Kl  solution  used) 
c.c.  blood  filtrate  taken 

5.  Acetone  in  the  Blood. — It  sometimes  occurs  that  acidosis  is 
present  yet  is  not  disclosed  by  the  simple  ferric  chloride  test  for 
diacetic  acid  in  the  urine.  It  has  long  been  realized  that  the  analy- 
sis of  the  blood  would  give  a  more  reliable  index  of  the  condition 
of  the  patient,  but  the  methods  for  examination  have  been  so  com- 
plicated as  to  preclude  their  general  adoption.  Recently  Miss 
Mary  15.  YVishart,  of  the  Rockefeller  Institute  for  Medical  Research, 
devised  the  following  method,  and  I  am  indebted  to  Miss  Wishart 
for  the  privilege  of  inserting  it  here.  It  can  readily  be  applied  by 
any  physician. 

(a)  Wishart  Method  for  Detection  of  Acetone  in  the  Blood. — The  blood 
is  drawn  into  a  syringe  or  tube  containing  a  few  crystals  of  potassium 
oxalatc,  then  ceutrifuged  for  five  minutes  at  medium  speed.  The 
test  is  made  on  the  plasma  with  as  little  delay  as  possible,  as  there 
is  liable  to  be  some  loss  of  acetone  on  standing. 

For  a  small  quantity  of  plasma.  (0.5  c.c.  or  more)  add  solid 
ammonium  sulphate  until  plasma  is  thoroughly  saturated  and  pro- 
tein precipitated;  then  add  two  or  three  drops  of  a  freshly  made 
f>  per  cent,  solution  of  sodium  nitroprusside  and  a  few  drops  of 
concentrated  ammonium  hydrate.  If  the  test  is  positive,  in  from 
one  to  ten  minutes  a  color  develops  which  runs  all  the  way  from  a 
pale  lavendar  to  that  of  a  deep  permanganate  hue,  in  this  way 
indicating  whether  much  or  little  acetone  is  present.  This  is  an 
adaptation  to  the  plasma,  of  the  Rottura  nitroprusside  reaction  as 
ordinarily  used  for  urine.  It  is  said  to  be  sensitive  to  1  part  in  20,000. 

(h )  Van  Slyke-Fitz  Methods  for  Determination  of  /3-hydroxybutric  Acid, 
Diacetic  Acid,  and  Acetone  in  Urine  and  Blood.  (See  page  194.) 

(I.  Carbon  Dioxide  in  Blood  Plasma. — Whether  in  health  or  in 
disease,  the  reactions  of  the  body  remain  nearly  constant  and  the 
blood  not  only  conforms  to  tins  general  law  but  helps  to  enforce  it. 
This  end  is  accomplished  in  the  presence  of  acidosis  (a  condition  in 
which  there  is  an  increase  in  the  quantity  of  /3-oxybutyric  acid  in 
the  body)  by  removing  the  ( '()•>  from  the  blood  to  make  way  for  the 
stronger  acid.  Therefore  a  determination  of  the  quantity  of  ('();> 
in  the  blood  is  an  index  of  the  degree  of  acidosis.  Recently  Van 
Slyke  has  devised  a  comparatively  simple  method  by  which  the 


EXAMINATION  OF  THE  BLOOD  215 

carbon  dioxide  capacity  of  the  blood  plasma  can  be  determined. 
I  am  very  fortunate  in  being  able  to  include  a  description  of  the 
method  furnished  me  by  Dr.  Van  Slyke  and  in  the  method  which 
follows  he  has  made  various  modifications  to  prevent  changes  in  the 
content  of  C()2  in  the  plasma  during  the  performance  of  the  test. 
In  general,  the  per  cent,  of  CO2  in  the  blood  plasma  stands  in  close 
relation  to  the  per  cent,  of  CO*  in  the  alveolar  air.  This  was 
originally  shown  by  Van  Slyke  and  has  been  confirmed  by  Walker 
and  Frothingham,1  who,  however,  noted  that  the  correspondence 
in  diabetes  was  not  as  close  as  in  other  diseases,  and  Van  Slyke'2 
stated  that:  "In  one  type  of  diabetes,  however,  especially  when 
on  a  low  calorie  diet,  a  low  alveolar  CO2  content  may  be  found 
while  the  blood  bicarbonate  is  still  normal.  This  emphasizes  the 
fact  that  the  carbon  dioxide  content  of  the  expired  air  is  only  an 
indirect  measure  of  the  blood  bicarbonate  and  is  dependent  for  its 
accuracy  upon  a  normal  respiratory  apparatus  and  a  normal  respira- 
tory center.  The  close  correspondence  in  such  a  variety  of  cases 
between  plasma  bicarbonate  and  alveolar  CO2  shows  the  tenacity 
with  which  normal  respiratory  regulation  is  usually  maintained." 
In  Table  101  this  same  variation  is  to  be  seen  in  Cases  Nos.  7 (SO, 
1051,  10S5  and  1103,  who  were  patients  living  on  an  extremely  low 
diet.  Austin  and  Jonas3  have  also  used  the  method  extensively. 
In  the  revised  description  of  the  method  given  below  their  observa- 
tions about  changes  in  the  content  of  C()2  in  the  plasma,  during 
the  test  are  met. 

The  combining  power  of  the  blood  plasma  for  CO2  has  been 
determined  upon  23  of  my  patients — a  much  smaller  proportion 
than  would  have  been  necessary  had  not  acidosis  ceased  to  be  a 
frequent  factor  in  the  cases  at  the  hospital.  The  results  are  tabu- 
lated to  show  the  outcome  of  the  cases  under  the  varying  degrees 
of  acidosis  thus  found,  the  comparison  between  the  blood  and 
alveolar  CO2  and  the  relation  of  both  to  the  ferric  chloride  test  for 
diacetic  acid. 

Three  fatal  cases  occurred  in  the  group.  Case  Xo.  1 143  entered 
the  hospital  in  diabetic  coma  and  died  the  same  day.  The  C()2 
was  10  in  terms  of  mm.  Ilg.,  and  this  is  the  lowest  quantity  we  have 
observed.  Case  No.  1053  with  gangrene  showed  a  plasma  content 
of  COo  of  only  21  in  terms  of  mm.  Ilg.  tension  five  days  before 
death  and  this  dropped  to  12  mm.  Ilg.  tension  two  days  before  the 
termination  of  coma.  For  a  fuller  description  of  this  case,  see  p. 
2S5.  Case  No.  10S5  died  of  inanition  after  leaving  the  hospital, 
sixteen  days  after  the  test  (see  p.  340). 

1  Walker  and  Frothingham:  Arch.  Int.  Mod.,  1910,  xviii,  p.  ;$()4. 

2  Van  Slyke:    Eighth  Annual  Meeting  of  the  American  Society  for  Clinical  Inves- 
tigation, 1910,  p.  25. 

3  Austin  and  Jonas:    Am.  Jour.  Med.  Sc.,  1917,  cliii,  p.  81. 


2Ki     rmxK,  Biooj)  AND  RESPIRATION  IN  DIABETES 

TAHLK   101.     THK  COMBINING  POWER  OF  THK    BLOOD    PLASMA  IN    DIAHETES 

FOIl    CO-,    Co.MI'ARKI)    WITH    THK    CO-    IN    THE    A  I.VKOLAK    Alii    AND 
THK     Dl.U'KTIC    Adi)     IN    THK     UltlNK. 


I'lasnia  CO,         Alveolar  air 

Case 

No. 

Date. 

with                        ('(), 
subsequent        corresponding. 
observations.    Mm.  [Intension 

Diaec-tic        ^"    "f 
mil.          'lays  to 

coma. 

Mm.  11^.  tension 

19  10 

1143 

Oct.       S 

10                          14 

+  +                    1 

1053 

May   15 

21                          21 

+  +  +            5 

19 

12                          11 

+  +  +             1 

Fatal  cases    .     •         10s5 

Julv    11 

32 

0               12(1 

Aug.     2 

11                          2<i 

0               105 

Oct.     20 

44 

0                27 

!. 

30 

2S                     20-27 

+  +  +           Hi 

7s(i 

June    12 

24                        2S 

+ 

14 

35                        25 

SI.   + 

20 

50 

0 

22 

47 

0 

29 

4s                        34 

0 

1070 

Juno   23 

21                         20 

+  + 

27 

31                         2<» 

si.  + 

July      1 

23                        25 

0 

1103 

Aim.     9 

22                        2  1 

+  +  + 

13 

32                        20 

4- 

19 

31 

0 

23 

40                       24 

o 

1114 

Sept.  Hi 

24                     24-34 

4-  +  + 

1196 

Dec.      !) 

211                        22 

+  + 

11 

2<i                        20 

+  + 

14 

33                        27 

SI.   + 

1917 

Jan.       2 

3S                        31 

si.  + 

Living  cases 

•19                        32 
48 

0 
0 

1916 

47 

0 

1102 

Sept.  10 

27 

+  + 

1037 

Aim-   22 

30                        31 

+  +  + 

1  OHO 

July    14 

32 

si.  + 

1017 

1209 

Jan.       2 

33                        30 

-f 

1916 

His:; 

July    IN 

37 

0 

Kills 

June    10 

3s                       32 

+  + 

20 

51 

1079 

July     1  1 

39 

0 

47'.» 

Ann.    19 

39 

1051 

May  2(1 

39 

0 

I  OS] 

July    is 

11 

0 

(ill) 

July     14 

11 

0 

1  1  17 

Sept.     11 

41                         39 

Trace 

107(1 

July     is 

13 

0 

1  1  (  i.'j 

An-.    15 

15 

Trace 

1059 

June       1 

51 

0 

Four  patients  slunved  evidences  of  beginning  coma  and  the  (T)2 
in  the  plasma  varied  between  21  and  24,  thus  corroborating  the 
clinical  findings.  Three  of  these  are  alive  April,  H)17;  none  received 


EXAMINATION  OF  THE  BLOOD  217 

any  alkali  in  their  treatment.  Case  No.  786,  in  June,  1910,  con- 
tributed to  the  frontispiece  of  this  book,  but  he  died  in  April, 
1917,  while  being  treated  by  another  physician  with  radium! 
Case  Xo.  1070,  in  June,  1910,  was  six  months  pregnant,  and  three 
months  later  was  delivered  of  her  first  baby  at  the  hospital  by 
J.  C.  Ilubbard  with  a  Cesarean  section  under  local  anesthesia. 
Both  she  and  her  baby  remain  in  good  condition.  Case  Xo.  11  OH, 
onset  at  forty-six  years,  entered  the  hospital  five  years  later  in 
August,  1910.  She  now  lives  in  the  country  with  great  care  upon  a 
limited  diet.  Case  Xo.  1114  is  a  young  man  who  became  sugar- 
free  with  much  difficulty,  but  by  persistent  effort  acquired  a 
tolerance  for  10  grams  carbohydrate. 

Save  for  Case  Xo.  1196,  none  of  the  remaining  cases  caused 
anxiety.  Case  X*o.  1196  showed  marked  acidosis,  but  this  gradually 
disappeared  without  alkalis.  (See  p.  379.) 

The  close  correspondence  between  the  CO2  in  the  alveolar  air 
and  blood  is  gratifying,  and  will  give  confidence  to  those  who  are 
only  in  a  position  to  determine  the  former  value.  It  must  be  noted, 
however,  that  variations  from  the  rule  occur,  but  these  are  usually 
among  patients  in  extreme  undernutrition,  or  among  those  cases 
which  show  an  interference  with  the  natural  exchange  of  gases 
between  the  blood  and  the  outside  air.1  Case  X'o.  1239,  with 
abscess  of  the  lung,  showed  such  a  discrepancy. 

The  correspondence  between  the  results  of  the  ferric  chloride  test 
and  the  C()o  in  the  blood  also  are  a  source  of  satisfaction,  for  I  know 
that  the  ferric  chloride  test  is  the  practical  test  for  the  family 
doctor.  This  test  is,  if  anything,  more  consistently  in  agreement 
with  the  COo  in  the  blood  than  is  the  CO2  in  the  alveolar  air,  as 
determined  by  the  Fridericia  method. 

(o)  Van  Slyke's  Method  for  Determination  of  Carbon  Dioxide  Capacity 
of  Blocd  Plasma. — The  blood  is  drawn  from  a  vein  into  the  vessel 
containing  potassium  oxalate  powder.  A  sufficient  amount  to  make 
1  per  cent.,  or  somewhat  less,  of  blood  is  taken.  If  the  blood  is 
drawn  into  a  vessel,  such  as  a  McKae  tube,  which  permits  contact 
with  air,  it  must  not  be  submitted  to  any  agitation  except  gentle 
inversion  once  or  twice  to  mix  the  oxalate,  and  should  be  centrif- 
ugated  at  once,  or  two  errors  may  occur.  The  chief  error  is  due  to 
escape  from  the  plasma  of  carbonic  acid,  as  a  result  of  which  approxi- 
mately an  equivalent  of  IICl  diffuses  from  the  corpuscles  into  the 
plasma.  The  net  effect  is  that  by  internal  aeration  one  can 
change  as  much  as  one-third  of  the  plasma  XaIICO;!  into  XaCl. 
Unless  the  above  precautions  can  be  observed  it  is  advisable  to 
collect  the  blood  in  a  syringe  containing  no  gas  space,  or  in  a 

1  Peters:    Am.  Jour.  Phys.,  1917,  xliii,  p.  113. 


218        rit/XE,    BLOOD  AXD   KEKPIKATIOX   IX   DIAHETEX 

centrifuge  tube  under  a  layer  of  paraffin  oil.  In  order  to  avoid  the 
reverse,  ell'ect,  viz.,  overaccumulation  of  ('();>  in  the  venous  blood,  it 
is  advisable  when  ligature  is  used  to  release  it  as  soon  as  the  vein 
is  entered,  and  to  allow  a  short  time  for  the  stagnant  blood  to  be 
washed  out  of  the  vein  before  the  main  sample  is  drawn.  A  second 
and  lesser  error,  which  appears  to  be  significant  only  when  the  whole 
blood  stands  over  an  hour  before  centrifuging  is  due  to  apparent 
formation  of  organic  acids  by  the  corpuscles,  and  results  in  lowering 
of  the  bicarbonate.  The  plasma  once  separated,  however,  may  be 
kept  for  analysis  at  leisure,  any  loss  of  (X)2,  by  such  reactions  as 
2NaIirO.i  =='  Xa,(X),  +  H,CO»,  being  made  good  before  the 
analysis  by  resaturating  with  ('()2  at  alveolar  tension  as  described 
below. 

The  clear  plasma,  being  pipetted  oil',  should,  in  case  it  is  not 
convenient  to  determine  its  carbon  dioxide  capacity  at  once,  be 
transferred  to  a  paraffin-lined  tube,  where  it  will  keep  unchanged 
for  a  week  if  placed  on  ice. 

In  order  to  determine  its  alkaline  reserve,  the  plasma  is  satu- 
rated with  carbon  dioxide  at  alveolar  tension.  For  this  purpose  the 
plasma  (about  o  c.c.  if  there  is  plenty  of  material),  which  should 
be  at  room  temperature,  is  placed  in  a  separatory  funnel  of  about 
)!()()  c.c.  capacity,  and  the  funnel  is  filled  with  alveolar  air  from  the 
lungs  of  the  operator.  The  air  is  passed  through  a  bottle  full  of 
glas*  beads  before  it  enters  the  funnel,  in  order  to  bring  the 
moisture  content  down  to  saturation  at  room  temperature.  If  one 
blows  directly  into  the  separatory  funnel,  enough  moisture  condenses 
on  the  wall  to  appreciably  dilute  the  plasma.  The  funnel  is  closed 
just  before  the  stream  of  breath  stops,  and  is  shaken  for  one  minute 
in  such  a  manner  that  the  plasma  is  distributed  as  completely  as 
possible  about  the  walls,  forming  a  thin  layer  which  quickly 
approaches  equilibrium  with  the  carbon  dioxide  in  the  air.  After 
the  shaking  has  lasted  a  minute,  a  fresh  portion  of  the  alveolar  air  or 
of  5.5  per  cent,  carbon  dioxide  fr«m  a  gas  tank,  is  run  into  the 
funnel,  and  the  shaking  completed. 

The  determination  of  the  carbon  dioxide1  content  of  the  saturated 
plasma  is  performed  as  follows :  The  carbon  dioxide  apparatus  (Fig.  7) 
held  in  a  strong  clamp  on  a  ringstand,  is  completely  filled  with 
mercury  which  should  fill  both  capillaries  above  the  upper  stop- 
cock. The  mercury  leveling  bulb  is  placed  about  on  a  level  with 
the  lower  cock.  The  cup  at  the  top  of  the  apparatus  is  washed 
out  thoroughly  with  dilute  ammonia  followed  by  water,  medicine 
droppers  being  convenient  for  this  purpose.  One  cubic  centimeter 
of  the  saturated  plasma  is  now  introduced  into  the  cup,  and  allowed 
to  flow  down  into  the  upper  stem  of  the  apparatus.  The  cup  is  now 
washed  with  two  portions  of  about  0.5  c.c.  each  of  water,  care  being 


EXAMINATION  OF  THE  BLOOD 


taken  that  no  air  enters  the  apparatus  with  the  liquid.     One  small 

drop  of  redistilled  caprylic  alcohol,   to  prevent    foaming,   is  now 

admitted  into  the  capillary  connecting  the  cup 

with  the  upper  end  of  the  apparatus,  and  about 

1  c.c.  of  5  per  cent,   sulphuric  acid  is  poured 

into  the    cup.     Enough   of   the   acid    is    now  ^ 

carrying    the          ^ 
so  that    the  £ 

apparatus   is 
mercurv  is  now 


admitted    into    the    apparatus, 
caprylic   alcohol    along    with    it, 
total    volume  of   water   in   the 
exactl     2.5  c.c.     A   drop  of 


bore 


3  mm.  bore 


placed  in  the  cup  and  allowed  to  flow  down 
to  the  upper  stop-cock  in  order  to  seal  same, 
and  make  it  capable  of  holding  an  absolute 
vacuum.  The  leveling  bulb  (the  lower  cock 
having  remained  open  from  the  beginning  of 
operations)  is  lowered  to  a  point  such  that  the 
surface  of  the  mercury  in  it  is  about  800  mm. 
beloAV  the  lower  stop-cock,  and  the  mercury 
in  the  apparatus  is  allowed  to  fall  until  the 
meniscus  of  the  mercury  has  dropped  to  the 
50  c.c.  mark  on  the  apparatus.  As  the  latter 
is  evacuated,  bubbles  of  carbon  dioxide  are 
seen  escaping  from  the  water  mixture  in  the 
vacuum. 

In  order  to  completely  extract  the  carbon 
dioxide,  the  apparatus  is  removed  from  the 
clamp  and  shaken  by  turning  it  upside  down 
about  a  dozen  times.  It  is  then  replaced, 
the  mercury  leveling  bulb  still  being  at  the 
low  level,  and  the  water  solution  is  allowed  to 
flow  completely  into  the  small  bulb  below 
the  lower  stop-cock.  The  water  solution  is 
drained  out  of  the  portion  of  the  apparatus 
above  the  stop-cock  as  completely  as  possible, 
but  without  removing  any  of  the  gas.  The 
mercury  bulb  is  now  raised  in  the  left  hand, 
and  the  lower  stop-cock  is  turned  with  the 
right  hand  so  that  mercury  is  admitted  to 
the  apparatus  through  the  left-hand  entrance 
of  the  3-way  cock  without  readmitting  the 
water  solution.  The  leveling  bulb  is  held 
beside  the  apparatus  so  that  the  mercury  level 

in  it  is  even  with  that  in  the  apparatus,  and  the  gas  in  the  latter  is 
under  atmospheric  pressure.  A  few  hundredths  of  a  cubic  centi- 
meter of  water  will  float  on  the  mercury  in  the  apparatus,  but  this 


FIG.  7.— Van  Slyke's 
pipette  for  determining 
the  combining  power  of 
the  blood  for  carbon  di- 
oxide. 


220       URINE,   BLOOD  AXD  HEM'IltATION  IN   DIABETES 


may  be  disregarded  in  leveling.      The  volume  of  gas  above  the 
short  column  of  water  referred  to  is  at  once  read  oil'. 

The  calculation  of  the  result  into  terms  of  volume  percentage  of 
carbon  dioxide  bound  as  carbonate  by  the  plasma  is  quite  compli- 
cated, and  Van  Slyke  consequently  computed  a  table  which  obviates 
the  necessity  of  calculation.  (Table  102.) 


TABU:   102. — VAX   SI.VKE'S  TAKLK   FOR  CALCULATION 


( Ibservcd 

vol.  «:is 

<    7t,0 

0   20 

1 

3 

4 

5 

0 

7 

s 

9 
0.30 

1 

2 

3 

4 

5 

(i 

7 

8 

9 
0.40 

1 

3 

4 
5 

t; 

7 
S 
9 

0.50 
1 
•> 

3 

4 
5 
(i 
7 
S 
9 
O.C.O 


H.-tr. 


Plasmas  of  normal  adults  yield  0. ('•.">  to  0.00  c.c.  of  gas,  indicating 
").'!  to  77  volume  per  cent,  of  carbon  dioxide1  chemically  bound  by  the 
plasma.  Figures  lower  than  ,">()  per  cent,  in  adults  indicate  acidosis. 
The  normal  figures  for  infants  appear  to  be  K)  to  .">,">  per  cent., 
much  lower  than  for  adults. 


EXAMINATION  OF  THE  BLOOD  221 

Caution  in  setting  up  apparatus:  The  jaws  of  the  clamp  in  which 
the  apparatus  is  held  should  be  lined  with  thick,  soft  rubber.  The 
apparatus  should  be  clamped  very  tightly  because  of  the  weight  of 
the  mercury. 

In  order  to  prevent  the  apparatus  from  slipping  out  of  the  clamp, 
an  iron  rod  should  be  so  arranged  as  to  project  under  the  lower 
stop-cock,  so  that  it  will  support  the  apparatus  from  this  point,  in 
case  it  should  any  time  slip  down  from  the  clamp. 

The  temperature  figures  at  the  heads  of  columns  represent  the 
room  temperatures  at  which  the  samples  of  plasma  are  saturated 
with  carbon  dioxide  and  analyzed.  It  is  assumed  that  both  opera- 
tions are  performed  at  the  same  temperature,  which  is  also  that  of 
the  solutions  analyzed. 

The  figures  have  been  so  calculated  that,  regardless  of  the  tem- 
perature at  which  the  plasma  is  saturated,  the  table  gives  the  volume 
(reduced  to  0°,  TOO  mm.)  of  carbon  dioxide  that  100  c.c.  of  plasma 
are  capable  of  binding  at  20°. 

If  the  figures  in  the  table  are  multiplied  by  0.94  they  give, 
approximately  (within  1  or  2  per  cent.),  the  volume  per  cent,  of  car- 
bon dioxide  bound  by  plasma  at  37°. 

If  the  figures  in  the  table  are  multiplied  by  0.09  they  give,  usually 
within  less  than  5  mm.,  the  alveolar  carbon  dioxide  tension  of  the 
plasma  donor  as  determined  by  the  Fridericia  apparatus. 

If  the  figures  in  the  table  are  multiplied  by  0.01904,  i.  e., 

Wt.  of  1  c.c.  carbon  dioxide  at  0°  700  mm., 
"100 

they  give  the  milligrams  of  carbon  dioxide  bound  by  1  c.c.  of  plasma. 

The  apparatus  can  be  obtained  from  E.  Greiner,  55  Fulton  Street, 
New  York. 

7.  The  Hydrogen-ion  Concentration  of  the  Blood. — A  simple 
method  for  determining  variations  in  the  hydrogen-ion  concen- 
tration of  the  blood  has  been  devised  by  Levy,  Rowntree  and 
Marriott,1  as  follows: 

"Serum  or  whole  blood  is  placed  in  small  collodion  sacs  and 
dialyzed  for  five  minutes  against  a  normal  saline  solution.  The 
hydrogen-ion  concentration  of  the  dialysate  is  determined  by  adding 
a  few  drops  of  phenolsulphonephthalein  and  comparing  the  color 
thus  obtained  with  that  produced  on  adding  the  indicator  to  a 
solution  of  kmrnn  hydrogen-ion  concentration.  A  determination 
can  be  carried  out  in  a  few  minutes  and  requires  only  from  1  to  3 
c.c.  of  blood  serum.  The  results  are,  in  general,  comparable  with 

1  Levy,  Rowntree  and  Marriott:  Arch.  Int.  Mod..  191"),  xvi,  p.  .'3s9.  and  as  abstracted 
in  the  Johns  Hopkins  Hospital  Bulletin,  1915,  xxvi,  p.  114. 


222        ritlXK,   BLOOD   AND   REKFIRATIOX  IN   DIABETES 

those  obtained  by  the  use  of  electrometric  methods."  (See  original 
article  for  discussion  of  its  significance  and  for  references  to  the 
subject.) 

S.  Titratable  Alkalinity  of  Blood.— Any  method  for  the  detection 
of  acidosis  which  depends  upon  the  examination  of  the  urine  is 
misleading  and  often  inapplicable.  Realizing  this  fact,  Sellards1 
undertook  to  supply  a  simple  clincial  method  for  determining  the 
alkalinity  of  the  blood  by  titration.  To  obviate  the  difficulties  of 
earlier  titration  methods  he  developed  a  purely  qualitative  technic 
in  which  all  normal  sera  would  react  distinctly  alkaline,  whereas 
pathological  sera  would  react  in  many  gradations  from  slightly 
alkaline  to  neutral  or  even  acid. 

The  difficulties  encountered  were:  (1)  the  selection  of  an  indi- 
cator to  which  all  normal  sera  were  alkaline  after  the  conversion  of 
the  acid  carbonate  (XaIl(X):i)  of  the  blood  to  normal  carbonates 
(XaaCOs);  (12)  the  removal  of  the  interfering  proteins;  (o)  the 
substitution  of  another  solvent  for  water  to  reduce  the  amount 
of  hydrolysis  and  utilization. 

Sellards  finally  employed  a  solution  of  0.5  per  cent,  strength  ordi- 
nary diacid  phenolphthalein,  made  up  in  absolute  alcohol.  The 
removal  of  protein  and  the  substitution  of  another  solvent  for 
water  were  combined  in  one  step  by  precipitating  the  serum 
with  alcohol. 

The  determination  is  carried  out  in  three  steps  by  obtaining 
(1)  the  reaction  of  the  residue  after  incineration  in  platinum;  (2)  the 
reaction  after  dilution  with  water  and  boiling;  (.'>)  after  precipita- 
tion of  the  protein  with  alcohol,  the  reaction  of  the  alcoholic  filtrate. 

The  first  determination  is  carried  out  simply  by  ashing  one  or 
two  drops  of  serum  at  a  dull  red  heat  in  a  platinum  crucible.  The 
residue  is  dissolved  in  water  and  the  reaction  tested  with  phenol- 
phthalein. 

In  each  of  the  other  two  applications  1  c.c.  of  serum  is  added, 
drop  by  drop,  to  125  c.c.  of  absolute  ethyl  alcohol.  Tin1  mixture  is 
shaken  thoroughly  and  filtered  into  an  evaporating  dish.  Three 
or  four  drops  of  phenolphthalein  are  added  to  the  filtrate,  and  one 
of  these  evaporated  slowly  to  dryness  on  a  steam  bath.  This 
alcoholic  filtrate,  upon  concentration,  rapidly  takes  on  a  deep  red 
color.  This  change  takes  place  in  all  gradations;  from  the  normal, 
in  which  color  is  produced  early  and  retained  for  five  to  eight  hours 
with  constant  heating,  to  the  pathological,  where  the  color  is  lost 
after  a  few  minutes  of  heating,  or  may  not  appear  at  all  where  the 
depletion  of  alkali  is  marked,  as  in  extreme  acidosis  in  diabetes. 

The  author  concludes  that  in  all  normal  individuals  the  unheated 

1  Bollards:  Johns  Hopkins  llo.-p.  Bull.,  1'Jll,  xxv,  p.  101. 


EXAMINATION  OF   TUK  RESPIRATION  22:} 

alcoholic  filtrate  of  the  serum  is  neutral,  or  slightly  acid,  to  phenol- 
phthalein,  and  becomes  alkaline  upon  heating. 

The  reactions  are  listed  in  the  following  stages  and  merge  grad- 
ually into  one  another: 

1.  Persistence  of  red  color  in  either  alcoholic  solution  or  dry 
residue  for  several  hours. 

2.  Absence  of  color  in  alcoholic  solution  or  transient  appearance 
of  color  in  the  residue,  but  with  good  coloration  in  aqueous  solution. 

3.  Total  absence  of  color  in  alcoholic  solution,  in  the  residue  on 
evaporation  or  after  the  addition  of  water,  but  with  distinct  color 
in  the  aqueous  solution  before  removal  of  protein. 

4.  Total  absence  of  color  in  all  stages,  including  the  aqueous 
dilution,  without  the  removal  of  protein.     (This  latter  test  is  made 
with  a  1  to  ]()  dilution  of  the  whole  serum  in  water.) 

9.  Total  Solids. — Myers  and  Fine1  show  how  the  total  solids  of 
the  blood  may  be  very  simply  and  accurately  determined.  They 
use  a  weighing  bottle  of  the  ordinary  style,  with  stopper  having  a 
glass  loop  to  which  a  block  of  filter  paper  may  be  fastened  with  a 
small  wire  hook.  The  block  of  filter  paper  is  suspended  and  the 
bottle  dried  and  weighed.  From  a  small  pipette  0.3  to  0.0  gram 
of  the  well-mixed  blood  is  allowed  to  flow  on  the  filter  paper  rapidly, 
the  stopper  quickly  inserted  to  prevent  loss  of  moisture,  and  the 
bottle  weighed.  The  stopper  is  now  tilted  and  the  bottle  placed 
in  the  drying  oven  at  105°  (\  overnight.  When  convenient  the 
bottle  is  cooled  and  again  weighed.  From  the  loss  of  moisture 
the  total  solids  may  readily  be  calculated. 

At  the  eighth  meeting  of  the  American  Society  for  Clinical  Inves- 
tigation, 1910  (see  report,  p.  29),  Mosenthal  described  a  method  in 
which  little  tin  boxes  were  used  for  the  determinations.  From  his 
investigations  he  concluded  that  the  body  has  a  tendency  to  increase 
the  water  content  of  the  blood  as  the  blood  sugar  rises.  Other 
factors  like  diuresis  break  in  on  this  parallelism. 

C.     EXAMINATION  OF  THE  RESPIRATION. 

1.  The  Technic. — Two  types  of  apparatus  are  employed  to  learn 
the  exchange  of  carbon  dioxide  and  oxygen  in  man:  the  respiration 
calorimeter  and  the  respiration  chamber,  which  are  the  same  in 
principle,  and  the  respiration  apparatus.  In  the  closed  chamber  of 
the  calorimeter  and  the  respiration  chamber,  the  oxygen  admitted 
and  the  carbon  dioxide  withdrawn  can  be  accurately  determined 
in  periods  from  one-half  to  one  hour's  duration,  but  it  is  better  to 
take  the  average  of  the  results  obtained  in  three  successive  periods. 

1  Myers  and  Fine:  Chemical  Composition  of  the  Blood  in  Health  and  Disease, 
Post-Graduate,  New  York,  1914-1915. 


224        URINE,   BLOOD  AND   RESPIRATION   IN   DIABETES 

In  the  new  respiration  chamber  recently  devised  by  Benedict,1 
and  shown  in  the  accompanying  illustration,  half-hour  periods 
have  proved  very  satisfactory.  The  calorimeter  is  cumbersome, 
expensive  to  construct  and  maintain,  and  the  length  of  the  experi- 
ment is  not  only  disagreeable  to  the  patient  but  disadvantageous 
in  studying  the  results  of  rapid  changes  in  the  metabolism,  which 
are  desirable  in  a  study  of  the  utilization  of  foods.  The  respiration 
chamber  is  similar,  but  simpler  in  construction,  is  available  for 


FKJ.  S. — General  view  of  the  complete  clinical  respiration  apparatus  installed  in 
the  respiration  laboratory  of  the  Brodbeck  Memorial  Cottage,  X.  K.  Deaconess 
Hospital,  Boston,  Mass.  Respiration  chamber  on  the  left.  The  thermometers, 
with  reading-glass  attachments,  in  the  cover;  kymograph  for  registering  the  muscular 
activity  on  the  left.  Universal  respiration  apparatus  in  the  center.  Below  arc 
the  rotary  blower,  the  motor,  and  the  Williams  bottles;  above  are  the  spirometer, 
soda-lime  bottles,  Williams  bottle,  and  petroleum  manometer.  At  the  extreme 
right  are  the  barometer,  oxygen  cylinder,  and  Bohr  meter  under  water. 


shorter  periods,  and  serves  all  the  purposes  and  has  all  the  advan- 
tages of  the  calorimeter  save  that  there  is  no  direct  measure  of 
heat.  However,  this  is  not  of  consequence  because  it  is  possible 
to  determine  the  heat  given  oil'  by  the  patient  accurately,  but 
indirectly,  from  the  oxygen  inhaled  or  less  accurately  from  the 
carbon  dioxide  given  oil'. 

1  Sec  Benedict  and  Tompkins:  Boston  Mod.  and  Surg.  Jour.,  1910,  clxxiv,  p.  <s.">7, 
for  a  clear  statement  of  the  subject  of  "Respiratory  Exchanges,  with  a  Description 
of  a  Respiration  Apparatus  for  Clinical  Use." 


EXAMINATION  OF  THE  RESPIRATIOX  22"} 

The  respiration  apparatus  differs  from  the  calorimeter  and  respira- 
tion chamber  in  that  the  patient  is  not  in  a  closed  chamber,  but 
instead  breathes  through  a  nose-  or  mouth-piece.  This  is  advan- 
tageous because  the  exchange  of  gases  can  be  determined  during 
short  periods  of  fifteen  minutes  or  less.  It  is  disadvantageous, 
however,  because,  the  periods  being  so  short,  errors  at  the  begin- 
ning and  end  of  the  periods  are  magnified,  and  further,  because  of 
the  individual  breathing  through  a  nose-piece  or  mouth-piece  an 
abnormal  state  is  introduced.  Unfortunately,  in  each  form  of 
mouth-  or  nose-breathing  apparatus  the  error  of  a  leak  falls  chiefly 
on  the  oxygen,  because  the  patient  and  the  apparatus  constitute  a 
closed  circuit,  and  any  diminution  in  gas  in  this  circuit  must  be 
offset  by  the  addition  of  oxygen.  A  more  troublesome  source  of 
error  and  one  difficult  to  avoid  arises  from  the  possibility  of  the 
patient  exhaling  carbon  dioxide,  which  has  previously  accumulated 
in  the  body,  at  a  more  rapid  rate  than  corresponds  with  the  oxygen 
inhaled.  The  patient  is  said  to  "pump  out"  carbon  dioxide.  This 
error  could  only  occur  in  the  relatively  short  periods  which  are 
employed  witli  the  respiratory  apparatus.  There  is  also  another 
error  due  to  carbon  dioxide  which  is  lost  by  cutaneous  respiration, 
and  it  has  been  calculated  that  this  would  lower  the  quotient  0.01 
to  0.015.  This  also  occurs  only  with  the  respiratory  apparatus. 

Many  pitfalls  therefore  lurk  in  the  determination  of  the  respira- 
tory exchange  of  an  individual.  The  carbon  dioxide  is  the  more 
easily  estimated  of  the  two  gases,  and  in  early  experiments  on 
metabolism  investigators  attempted  to  estimate  this  alone.  The 
determination  of  oxygen  is  far  more  difficult.  In  dealing  with  the 
respiratory  quotient,  which  depends  on  the  relation  of  these  two 
determinations  to  each  other,  the  problem  is  still  more  complicated 
and  all  statements  regarding  the  respiratory  quotient  of  individuals 
must  be  accepted  with  caution.  The  general  picture  of  the  respira- 
tory quotient  in  an  individual  is  far  more  valuable  as  a  guide  to  his 
true  metabolism,  if  based  on  several  experiments,  than  is  the  result 
of  a  single  experiment.  Similarly,  it  is  probably  safer  to  average 
the  results  of  a  series  of  cases  than  to  attach  great  importance 
to  figures  obtained  in  an  isolated  experiment. 

2.  The  Respiratory  Quotient. — The  relation  which  the  volume  of 
carbon  dioxide  exhaled  bears  to  the  volume  of  oxygen  inhaled 
constitutes  the  respiratory  quotient.  The  respiratory  quotient  has 
been  discussed  at  length  in  Section  II,  G,  2,  to  which  the  reader  is 
referred.  During  the  combustion  of  a  food  in  the  body  a  definite 
quantity  of  oxygen  is  consumed  and  carbon  dioxide  produced.  The 
relation  which  the  volumes  of  carbon  dioxide  and  oxygen  bear  to 
one  another  constitutes  the  theoretical  respiratory  quotient  of  the 
substance.  I  will  insert  here  examples  showing  how  the  respiratory 
15 


220       URINE,   BLOOD  AND  RESPIRATION  IN   DIABETES 


*o 

h«   Cl  CJ 

—  "-*• 

_ 

-f  (N 

X— 

CT  O 

c;  c; 

~ 

—  1^ 

to 

•^r  co 

'C  irr 

>rt 

^  CC 

ic 

•  c  i~ 

P-, 

5    ?    C 

v:  r^ 

1- 

y  c^i 

X  C-1 

M  ~'*~ 

u  L*  c  ~ 

~l 

X 

1^  t- 

J                      •                   >—<    C 





:                  5  £- 

L.  *  ?• 

;=  It 

= 

ei  cr. 
i^  i^ 

0 

X  X 

->                                                 0    C 

t.e  ».*7 

1  ~ 

^t-  -r 

"* 

-r  "t1 

<                                                       0 

< 

r                                  —  £ 

S                     2  a_. 

•*  ce 

*,-  -,- 

(N 
CM 

C   "H 

<                      «  ?•  ? 

, 

--^  -^ 

PC 

^^.  ^-. 

re 

ce  ce 

:                  £  o 

<                                    £    =    ?       0 

^  —  ;  '.  ) 

— 

i—  i  ce 

c^ 

C2  1^ 

£•£  ~   -' 

~ZZ  ^Z 

t^t^ 

X 

X  ;c 

r"                    5T  ~  Q  O 

T—  1    1—  1 



c  o 

^  —  • 

oo 

^ 

•* 

o  -t 

3- 

i       .I1        s  L" 

"M  C". 

t^ 

dd 

- 

— 

M                        ^ 

c 

-               X             ^           3  ". 

ce  '^ 

C^  '^7 
C-l  X 

~\ 

—  • 
1  - 

re  ?i 

1- 

C  (M 

X  ~ 

M                                                                                                                           'ti       - 

?j  ^ 

— 

x  r^ 

5 

X  « 

i            =          w         -  tt 

^                    *"                                  •*" 

—   — 

,— 

ei  ei 

i—  ( 

^—  ^^ 

r.                                 c 

re  'C 

(N 

ei  x 

C^ 

O  1C 

-*                    *^                                   "    -L. 

^t  i  ^ 

r^ 

T'J  ^  J 

•^ 

X  ~ 

"                   "     "                          —    ^,' 

ei  V. 

— 

•  —  C"- 

'^7 

tC  iC 

EC            > 

?1  •-• 

-' 

•"  ^^ 

^                   S    SI 

:       f,|         «T. 

"X  6l 

s 

•-C  -t 

-f.  X 

s 

m 

.-  u 

ei  'M 

r-  -M 

_2 

,, 

"C 

c 

:.I 

•—  — 

-  "t; 

rt 

^  •/. 

^ 

"^  •— 

—  - 

f    C 

f-~. 

C  i 

^ 

.5  S 

~  S 

•r-r 

x  C 

— 

*^  "~^ 

^^ 

< 

K         si    <^    O 


x  K  5  2 


EXAMINATION  OF  THE  RESPIRATION  227 

quotient    of   alcohol    and    milk    may    be    theoretically   calculated, 
because  the  computations  are  based  on  different  methods. 

The  oxidation  of  alcohol  (CgHsOH)  requires  3  molecules  of 
oxygen  (3(O2),  for  its  complete  combustion,  us  is  indicated  in  the 
following  equation : 

C1 

C2H6()H  =H4  +3(02)  =3(H20)  +2(CCh).    V/)hlme  2      "z)  =  Q.G7,  respiratory 

H-O-H  Volume  3(O2)      quoticnt  ,)f  aicohol. 

The  calculation  of  the  theoretical  respiratory  quotient  of  milk  is 
dependent  upon  the  fact  that  milk  is  made  up  of  known  quantities 
of  milk-sugar,  fat,  and  protein,  and  that  the  quantities  of  oxygen 
consumed  and  carbon  dioxide  given  off  in  the  combustion  of  each 
of  these  substances  have  been  determined.  These  values,  as  well 
as  some  others,  are  shown  in  Table  103. 

One  liter  milk  may  be  considered  to  contain  50  grams  of  carbo- 
hydrate, 40  grams  of  fat,  and  33  grams  protein. 

C.  (50  grains  X  74(5.2)  =  37,310.0  c.c.  CO2 
F.  (40  grams  X  1431.1)  =  f)7,244.0  c.c.  CO2 
P.  (33  grains  X  773.8)  =  25,535.4  c.c.  CO2 


120,089.4  c.c.  COo 

C.  (50  grams  X  746.2)  =  37,310.0  c.c.  Oo 
F.  (40  grams  X  2013.2)  =  80,528.0  c.c.  O2 
P.  (33  grams  X  956.9)  =  31,577.7  c.c.  O2 

149,415.7  c.c.  Oo 
120,089.4  c.c.  COo 
14C)  41"  "  c  c  Oo     =  0-803,  respiratory  quotient  of  milk. 

The  calculations  to  determine  the  respiratory  quotient  of  an 
individual  are  still  simpler,  and  are  shown  in  an  experiment  dis- 
cussed under  the  Total  Metabolism  in  the  following  paragraph. 

3.  The  Total  Metabolism.— The  total  metabolism,  with  its 
variations  in  diabetic  patients  at  different  stages  of  the  disease, 
has  been  discussed  in  Section  II,  G,  1 .  The  calculations  by  which 
the  total  metabolism  of  an  individual  can  be  determined  when  the 
oxygen  consumed  and  the  carbon  dioxide  exhaled  are  known  are 
illustrated  in  the  data  of  the  following  experiment  (Table  104): 

TABLE  104. — NORMAL  INDIVIDUAL  (E.  P.  .!.).     EASTING  EXPERIMENT 
DECEMBER  23,  1914      WEIGHT,  65  KILOS.     HEIGHT,  177.8  CM. 

CO?  Oa  Calories 

Duration.  nor  min.  per  min.  Respiratory  per  kilo 

Period.  min.          sec.  c.c.  c.c.  quotient.  per  24°. 

1  15  6  152  192  0.79  20.40 

2  14         59  150  194  0.77  20.51 

3  15          0  153  196  0.78  20.77 

Average  =  0 . 78 


22X       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

"First,  the  calculation  of  the  respiratory  quotient  of  this  individual 
should  be  determined,  and  this  is  done  as  follows: 

Volume  CO.,        152  c.c. 

T^-~r  —  =  O./O,  respiriitorv  mioticnt. 

\  olumc  ();>        192  (.•.(•. 

TABLE   105. — THK  ( 'ALOKIC  VALUE  OF  OXE  LITKU  OF  OXYOF.X  FOR  \'.\iuoi;s 

XOX-PKOTKIX   RKSI>IKATORY  QCOTIKXTS  AND  THK  PKOPOKTIOXS  OF  THK 

EXKHfiY   FROM    ( \\KHOH  VDKATK    AM)    I1' AT    M  KTA  HOLISM   TO   UK 

ASSIGNED  TO  CARBOHYDRATE  AND  FAT  RESPECTIVELY. 

(WILLIAMS,  KICIIK  AXD  LVSK.') 

Hespiratnry  Calorics  for  1   liter  Oo.  ( 'ar'nohydratc.  Fat, 

quotient.  Number.  \A>«.  percent.  ]>er  cent . 

0.70  .      .      .      .  4.0SO  0.070SO                    0  100.0 

0.71  ....  4.000  0.07110                    1.4  OS.Ii 

0.72  .      .      .      .  4.702  0.07231                    -1.8  05.2 

0.73  ....  4.714  0.07340                   S  2  01. S 

0.74  .      .      .      .  4.727  0.()74C>0  11.  (i  SS.4 

0.75  ....  4.730  O.C)7")74  lo.O  S.l.O 

0.7C)  ....  4.752  0.070SS  IS. 4  SI. (5 

0.77  .      .      .      .  4.7(54  0.()7S01  21.  S  7S.2 

0.7S  .      .      .      .  4.776  0.  ('.701:5  25.2  74. S 

0.70  ....  4.7SO  ().(iS()24  2S.C>  71.4 

O.SO  ....  4.  SOI  ().()S13l>  32.0  C.S.O 

0.81  .      .      .      .  4.S13  O.OS247  35.4  M.Ci 

O.S2  ....  4.S25  O.C.S35S  3S.8  111.  2 

O.S3  .      .      .      .  4.S3S  0.()S4f)0  42.2  57.  S 

O.S4  .      .      .      .  4.S50  O.OX57S  45.  ti  54.4 

O.S5  ....  4.<SI)3  O.USC.OO  40.2  51.0 

0.86  .      .      .      .  4.S75  O.OSSOO  52.0  47.  (i 

O.S7  .      .      .      .  4.SS7  O.GSOIO  55.4  41.2 

O.SS  .       .      .       .  4.000  O.tiOOlO  50.  S  40.  S 

O.SO  ....  4.012  0.0012S  112. (i  37.4 

0.00  ....  4.024  O.C.0230  ()(>.()  34.0 

0.01  ....  4.031)  O.(i0343  C.0.1  30.0 

0.02  .      .      .      .  4.04S  0.00450  72. S  27.2 

0.03  ....  4.  <)()()  ().()0557  70.2  23.  S 

0.04  ....  4.073  0.00004  70.  ti  20.4 

0.05  ....  4. OS5  0.00771  S3.0  17.0 

0.00  ....  4.007  O.OOS7S  SO. 4  13.0 

0.07  ....  5.010  O.OOOS5  SO.S  10.2 

O.OS  .      .      .      .  5.022  0.70002  03.2  O.S 

0.00  ....  5.034  0.70100  00.4  3.4 

1.00  ....  5.017  0.70307  100.0  0.0 

Since  the  body  weight  was  CM  kilos  and  ML'  c.c.  ()•_>  were  inhaled 
for  the  whole  body  per  minute,  LJ. '.).")  c.c.  (  1(.)2  c.c.  (K  -=-  CM  kilos) 
were  inhaled  per  kilo  per  minute,  and  as  there  are  fourteen 
hundred  and  forty  minutes  in  twenty-four  hours  ll'Sl.O  e.c.,  or 
•1.2X4  liters  oxygen  (1440  X  2.(.)."))  \\-ere  consumed  per  kilogram 
body  weight  per  twenty-four  hours.  In  order  to  express  in  terms 
of  calories  the  heat  which  any  consumption  of  oxygen  represents, 
\\illiams,  Kiche  and  Lusk  have  constructed  a  useful  table  (see 

1  William-,  Rk-he  and  Lu.-k:    Jour.  Biol.  C'hoin.,  1012,  xii,  p.  .'557. 


EXAMINATION  OF  THE  RESPIRATION  229 

Table  105)  showing  the  caloric  value  of  a  liter  of  oxygen  for  different 
non-protein  respiratory  quotients.  The  term  "non-protein  respira- 
tory quotient"  is  explained  in  a  later  paragraph. 

Consulting  this  table  of  Williams,  Riche  and  Lusk,  it  will  be  seen 
that  the  equivalent  in  calories  for  1  liter  of  ()2  for  a  non-protein 
respiratory  quotient  of  0.79  is  4.789.  (As  a  matter  of  fact,  the 
respiratory  quotient  above  obtained  is  not  the  exact  non-protein 
respiratory  quotient,  but  this  may  be  neglected  unless  the  nitrogen 
excretion  is  distinctly  abnormal.)1  If  we  multiply  4.7X9  calories 
by  the  total  number  of  liters  of  O2  consumed  per  day,  the  number 
of  calories  per  kilo  per  twenty-four  hours  is  obtained,  which  would 
be  in  this  case  (4.7S9  X  4.284)  20.5  calories.  It  should  be  stated  that 
this  actually  represents  the  metabolism  for  a  period  of  fifteen  minutes 
when  the  individual  was  under  complete  relaxation,  and  as  quiet 
as  possible.  It  by  no  means  represents  the  average  metabolism 
for  the  day.  Even  with  this  extreme  basis  of  repose  maintained  dur- 
ing the  experiment  the  weight  of  the  oxygen  inhaled  was  550  grams 
and  of  the  carbon  dioxide  exhaled  424  grams  in  the  twenty-four  hours. 

4.  The  Non-protein  Respiratory  Quotient. — If  the  nitrogen  in  the 
urine  is  known,  one  can  calculate  the  amount  of  oxygen  employed 
by  the  body  for  the  oxidation  of  the  protein  which  it  represents, 
and  correspondingly,  the  amount  of  carbon  dioxide  simultaneously 
produced.  If  these  computed  figures  are  substracted  from  the 
total  oxygen  and  carbon  dioxide  obtained  by  direct  experiment,  the 
remainders  represent  the  oxygen  absorbed  and  carbon  dioxide  pro- 
duced by  the  non-protein  respiratory  metabolism.  The  relation 
of  these  to  one  another  constitutes  the  non-protein  respiratory 
quotient.  In  the  table  of  Williams,  liiche  and  Lusk  the  proportions 
of  the  total  energy  from  the1  katabolism  of  carbohydrate  and  fat 
assumed  as  produced  from  the  two  materials  respectively  for  any 
known  non-protein  respiratory  quotient  between  0.70  and  1.00  are 
given.  Thus,  a  respiratory  quotient  of  0.70  shows  that  100  per  cent, 
fat  and  no  carbohydrate  was  oxidized,  and  a  respiratory  quotient  of 
1 .00  shows  exactly  the  reverse. 

The  calculations  necessary  for  the  determination  of  the  non- 
protein  respiratory  quotient  of  an  individual  are  given  below.  The 
example  chosen  for  this  purpose  is  that  of  a  man  undergoing  a  pro- 
longed fast  at  the  Nutrition  Laboratory.  (See  page  150  for  the 
complete  table.) 

Time. 
5th  day  of  fast 

1  It  will  bo  remembered  that  the  respiratory  quotient  of  protein  is  0.81  which  is 
nearly  that  here  obtained  for  the  total  metabolism. 

2  Calculated  for  twenty-four  hours. 


230       UlflXK,   BLOOD  AND   RESPIRATION  IN  DIABETES 

The  values  used  for  the  computation  of  the  above  data  were  as 
follows: 

('<>:>  <>2  Xitrouen 

c.c.  per  min.  grains  per  21  liours 

210  10.41 

10.41    grams    nitrogen    represents  the   nitrogen   excreted    per   24 

hours  or  1440  minute's,  and  (  ,         —-.•--)  0.0072  gram  is  the1  excreted 

\  1440  mm.  / 
nitrogen  per  minute. 

One  gram  of  protein  nitrogen,  representing  (>.()  grams  body  pro- 
tein,1 produces  in  its  combustion  4750  c.c.  (  O2,  and  consumes  in  its 
combustion  5010  c.c.  (),.  Therefore  (4750  X  0.0072)  34.20  e.c. 
CO.,  are  produced  per  minute,  and  (5910  X  0.0072)  42.55  c.c.  O2  are 
consumed  per  minute,  as  a  result  of  the  protein  metabolism. 

In  the  experiments  conducted  that  day,  the  total  (X)2  eliminated 
per  minute  was  estimated  at  175  c.c.,  and  the  total  ()2  consumed 
per  minute  at,  240  c.c.  These  two  amounts  represented  the  total 
metabolism  of  protein,  fat  and  carbohydrate  for  the  day.  If  the 
oxygen  and  carbon  dioxide  per  minute  derived  from  nitrogen,  which 
represents  the  protein  metabolism,  are  subtracted  from  the  total 
oxygen  absorbed  and  carbon  dioxide  produced  per  minute,  the 
remainders  show  the  non-protein  metabolism,  or  the  metabolism 
which  is  base: I  on  the  oxidation  of  fat  and  carbohydrate. 

17.">  c.c.  ( '( )o  per  min.    =    total       metab-  210  c.c.  ().,  per  min.     =    total        metal)- 

olism.  olism. 

34                                        =    protein  metab-  t.'-i                                     -    protein   metab- 
olism, olism. 

141  =    non-protein  107  =    non-protein 

metabolism.  metabolism. 

Volume  141  e.c.  f '( )., 

=  ().<2,   non-protein  respiratory  quotient.      (Ym.se- 
Volume  107  c.c.  <  )2 

quently  4. S  per  cent,  of  the  non-protein  metabolism  \va-  due  to  carbohydrate  and 
Of). 2  per  cent,  due  to  fat,  according  to  Table  10."). 

.  5.  Theoretical  Respiratory  Quotients  as  Calculated  from  the 
Diet. — The  theoretical  respiratory  quotient  of  a  normal  individual 
living  upon  protein  and  carbohydrate  can  be  calculated  as  shown 
in  the  following  table: 

TAHLK  10(5. — TIIKOUKTICAI.  KKSIMKATOKY  QTOTIKNTS. 

Diet.2  Cal.  (  >_.  TO, 

Protein,  100  grains    .       .       .        414  <)5.0'.>  77. 3S 

Carbohydrates,  503  grams   .     23(15  4(50.73  400.73 

502.42  544.11 

'In   estimating  the  quantity   of   body   protein   burned   from    the    nitrogen   in    the 
urine   the  equivalent    0  should   be  employed    instead    of   (i.2">. 
•-'Ma<mus-Levy:Ztschr.  f.  kliu.  Med.,  1005,  Ivi,  p.  .S3. 


EXAMINATION  OF  THE  RESPIRATION  231 

The  theoretical  respiratory  quotient  of  a  diabetic  individual  in 
which  the  carbohydrate  in  the  diet  has  been  replaced  by  fat  has 
been  calculated  by  Magnus-Levy,  and  he  has  also  inserted  the 
deductions  which  must  be  made  on  account,  first,  of  GO  grams  of 
dextrose,  and  second,  20  grams  of  /3-oxybutyric  acid  lost  in  the 
urine  during  the  same  period. 

TAHLE  107. — THEORETICAL  RESPIRATORY  QUOTIENTS. 

O2  COs  Respiratory 

Diet.1  Calories.  liters.  liters.  quotient. 

Protein,  100  grains 
Fat,  250  grams 


Dextrose,  00  grams 
/3-oxybutyric,  20  grams 


C'alories. 

02 

liters. 

CO2 

liters. 

414 
2365 

89.2 
504.9 

72.0 
350.8 

2779 

594.1 

428.8 

225  .  0 

44.8 

44.8 

2554 
91 

549  .  3 
19.3 

384.0 
17.2 

2403  530.0  300.8  0.092 


Lusk2  has  calculated  that  when  the  dextrose-nitrogen  ratio  is 
3.05  to  1 ,  the  quotient  of  protein  is  0.032.  The  formation  and  excre- 
tion of  acetone  bodies  also  tend  to  lower  the  quotient,  but  such  acid 
substances  may  react  with  sodium  bicarbonate  to  set  free  carbon 
dioxide,  so  that  the  precise  theoretical  value  of  the  quotient  in 
diabetes  cannot  be  determined.  The  actual  observations  in  phlo- 
rizinized  dogs  and  human  patients  with  the  3. Go  ratio  are  found 
to  meet  the  theoretical  expectations  with  quotients  approximating 
0.69. 

0.  The  Carbon  Dioxide  Tension  of  the  Alveolar  Air. — The  intro- 
duction of  simple  methods  for  the  detection  of  acidosis  by  deter- 
mination of  the  (X)2  in  the  alveolar  air  has  been  of  inestimable  value. 
In  1907  I  spent  a  week  in  Xaunyn's  laboratory  with  Magnus- 
Levy  in  order  to  learn  to  study  acidosis  by  familiarizing  myself 
with  the  latter's  method  for  the  estimation  of  /3-hydroxybutric 
acid.  The  analysis  was  most  time-consuming,  as  was  also  the 
quantitative  test  for  ammonia  by  the  Schlosing  method,  then  com- 
monly in  use,  which  demanded  an  interval  of  three  days  even  after 
the  twenty-four-hour  quantity  of  urine  had  been  collected.  The 
technic  of  Folin  in  1912  and  of  others  soon  reduced  this  latter 
process  to  less  than  half  an  hour,  but  even  then  the  result  obtained 
represented  the  average  excretion  for  the  preceding  twenty-four 
hours,  and  in  the  presence  of  approaching  coma  the  data  were 
obtained  too  late.  Therefore  newer  methods  which  enable  the 

'The  values  used  by  Magnus-Levy  for  C>2  and  CO->  vary  .somewhat  from   those 
given  in  the  more  recently  compiled  Table  106. 
2  Lusk:  Arch.  Int.  Mod.,  1915,  xv,  p.  939. 


232       URINE,   BLOOD  AND  RESPIRATION  IN   DIABETES 

acidosis  to  be  quantitatively  estimated  promptly  have  proven  most 
helpful  in  treatment.  At  present  three  such  methods  are  available 
for  the  detection  of  the  (X)2  in  the  alveolar  air,  the  Plesch-Higgins, 
the  Friderieia  and  the  Marriott.  Probably  the  Plesch-Higgins  is 
the  most  accurate,  and  those  familiar  with  it  in  large  hospitals 
prefer  it.  However,  the  other  two  methods  are  quite  satisfac- 
tory, and  the  techuic  of  either  one  can  be  learned  by  physician  or 
nurse  in  a  few  minutes. 

In  the  discussion  of  the  carbon  dioxide  capacity  of  the  blood 
plasma,  reference  is  made  to  the  fact  that  the  carbon  dioxide  of  the 
blood  diffuses  so  readily  into  the  alveolar  air  of  the  lungs  that  the 
estimation  of  the  latter  in  nearly  all  cases  gives  an  index  of  the 
former.  Because  of  the  simplicity  of  the  determination  of  the 
carbon  dioxide  in  the  alveolar  air,  it  is  today  the  best  quantitative 
method  which  the  physician  has  for  the  estimation  of  the  acidosis 
of  the  patient. 

Normally,  the  carbon  dioxide  tension  of  the  alveolar  air  varies 
between  MS  and  4o  mm.  mercury,  5.3  to  0.3  per  cent.  If  abnormal 
acids  are  present  in  the  blood,  these  displace  a  proportionate  amount 
of  carbon  dioxide,  and  as  the  carbon  dioxide  tension  in  the  alveolar 
air  bears  a  direct  relation  to  that  in  the  blood,  it  is  evident  that 
the  carbon  dioxide  in  the  alveolar  air  will  vary  likewise.  A  low 
carbon  dioxide  tension  of  the  alveolar  air  therefore  indicates  an 
acidosis.  If  the  carbon  dioxide  tension  lies  between  3S  and  32  mm. 
mercury  a  slight  acidosis  is  present,  between  32  and  2X  a  moderate 
acidosis,  and  if  it  falls  below  25  mm.  Ilg.  the  acidosis  is  extreme. 
The  lowest  value  with  recovery  in  my  group  of  cases  has  been  15 
and  the  lowest  obtained  in  the  series  was  9,  and  that  occurred  in  a 
patient  in  coma. 

Ilornor1  found  in  an  analysis  of  300  observations  of  the  alveolar 
COo  tension  of  my  cases  that  when  the  carbon  dioxide  tension  of 
the  alveolar  air  was  less  than  25  mm.  mercury  the  ammonia  was  3 
grains  or  more,  when  the  carbon  dioxide  tension  varied  between  25 
and  33  mercury  the  urinary  ammonia  varied  between  3.7  grams  and 
1.15  grams,  and  when  the  carbon  dioxide  tension  was  33  mm. 
mercury  or  over  the  ammonia  was  less  than  2  grams.  He  also 
studied  the  carbohydrate  balance  in  these  cases,  and  learned  that 
it  was  invariably  negative  when  patients  showed  a  tension  of  less 
than  25  mm.  mercury,  and  in  three-quarters  of  the  cases  was  nega- 
tive when  the  tension  was  between  25  and  33  mm.  mercury,  but 
that  at  a  higher  tension  the  carbohydrate  balance  was  usually  posi- 
tive and  invariably  so  when  the  carbon  dioxide  tension  was  above 
30  mm.  mer-nry.  The  ferric  chloride  reaction  was  also  observed, 

1  Hornor:  Boston  Mod.  and  Surg.  Jour.,  1910,  clxxv,  p.  148. 


EXAMINATION  OF  THE  RESPIRATION  233 

and  was  found  to  vary  from  negative  to  strongly  positive,  not  only 
when  the  carbon  dioxide  tension  of  the  alveplar  air  was  at  30  mm., 
but  also  at  23  mm.  The  absence  of  the  ferric  chloride  test  at  the 
lower  figure  speaks  in  favor  of  its  value  rather  than  otherwise, 
because  it  has  been  discovered  that  in  periods  when  the  patient  is 
on  a  low  caloric  diet  the  CO-,  in  the  alveolar  air  is  not  a  reliable 
index  of  the  extent  of  acidosis  of  the  patient.  (See  p.  215.) 

Case  No.  1120,  a  child  with  onset  of  diabetes  at  the  age  of  six 
years,  entered  the  hospital  eight  months  later  as  he  was  recover- 
ing from  definite  diabetic  coma.  Under  treatment  he  thoroughly 
recovered  from  acidosis,  but  upon  repeated  trials  increase  of  food 
led  to  the  return  of  both  sugar  and  acidosis.  In  one  of  these 
attempts  to  build  up  his  nutrition  severe  acidosis  developed  on  a 
diet  of  42  grams  protein  and  70  grams  fat.  Typical  hyperpnea 
without  cyanosis  developed  and  repeated  observations  showed  the 
CO2  tension  of  the  alveolar  air  to  be  15  mm.  Hg.  By  fasting 
and  without  the  use  of  alkalis  the  patient  promptly  came  out  of 
this  state,  but  he  later  died  from  inanition  without  a  trace  of 
acidosis,  representing  the  third  mortality  from  inanition  which  I 
have  had. 

The  importance  which  should  be  attached  to  varying  degrees 
of  acidosis  as  shown  by  the  CO2  tension  of  the  alveolar  air  is 
shown  by  Table  108,  which  gives  the  results  of  all  cases  since 
Dec.  1,  1915,  in  which  the  tension  has  been  found  to  be  below 
25  mm.  Hg. 

None  of  the  patients  cited  in  Table  108  took  alkalis,  and  hence 
the  table  is  an  index  of  this  method  of  treatment.  The  lowest  case 
in  our  series  showed  9  mm.  Hg.  tension  and  with  recovery  15  mm. 
Ilg.  tension.  When  the  patient  takes  sodium  bicarbonate,  the 
carbon  dioxide  tension  is  affected  and  it  may  rise  to  above  normal. 
Case  Xo.  513,  p.  353. 

(a)  Fridericia1  Method. — This  method  possesses  the  advantages  of 
being  simple  and  involving  the  use  of  apparatus  which  may  be 
easily  transported  to  the  bedside.  One  hundred  c.c.  of  alveolar  air  are 
collected  in  a  closed  chamber  and  then  cooled  from  the  temperature 
of  the  body  to  that  of  the  room.  The  carbon  dioxide  in  this  air 
is  then  absorbed  with  a  20  per  cent,  aqueous  solution  of  potassium 
hydrate,  thereby  creating  a  partial  vacuum  which  in  turn  is  equal- 
ized with  water.  This  water  is  then  subjected  to  atmospheric  press- 
ure, when  the  amount  of  carbon  dioxide  replaced  by  water  can  be 
read  in  percentage  of  atmospheric  air  by  reading  the  height  in  cm. 
to  which  the  column  of  water  has  risen  in  the  closed  100  c.c.  chamber. 
This  percentage  may  be  changed  to  millimeters  of  mercury  pressure 

1  Fridoricia:  Berliner  klin.  Wchnschr.,  1914,  li,  part  2,  p.  1268. 


234       URINE,   BLOOD  AND   RESPIRATION  IN  DIABETES 


TAHLE  108. — RESULTS  OF  TREATMENT  OF  ACIDOSIS  IN  PATIENTS  WITH 
ALVEOLAR  C()2  TENSION  25  MM.  MERCURY  OR  LESS. 


Fatal. 

Immediate  recovery    nit  later  fatal. 

Heeovery.     Alive  May,  1917. 

Alveolar  air 
No.               Date.                O  >2  tension, 
mm.  llfi. 

No. 

Date. 

Alveolar  air 
C(  >2  tension, 
mm.  llfi. 

No. 

Date. 

Alveolar  air 
C(  >2  tension, 
mm.  UK. 

904      April  29,  191  (i 
Died    4    days 
later 

1C'  /142 
Coma 

7(15 

Def.      G,  1915 
Jan.    24,  1910 
25 
Oet.    29 

21 
21 
24 
Coma 

9S3 

Feb.      1,  1910 
2 
3 

23 

25 

939      Nov.  30,  191(1 
Died     2     days 
later 

20 

Pulmonary 
embolism 

1070 

June  23,  191(1 
24 
July      1 
10 

20 
21 
25 
25 

9  12 

July    12,  191(1 
13 
1(1 
17 
18 
27 
AUK.    3 
Nov.     5 

20 
17 
24 
21 
24 
24 
24 
Coma 

1004 

Feb.    28,  191(5 

29 

Mar.     1 
Died  samp  day 

(    4.00  P.M. 
1    9.30  P.M. 
f     0.00A.M. 
1    11.00  KM. 
1-1—    9.00  A.M. 

Coma 

1011 

Mar.  10,  1910 
29 
April    3 
0 

13 

10 
20 
28 
Oct.     25 

29 

25 
24 
23 

25 
23  ,'24 
23  ,'22 
23 
25 
25 
24 
24 
25 

9(1(1 

Jan.       ">,  191(1             25/24 
July                     Coma 

1010 

Mar.  17,  191ti 
IS 
Died   5   hours 
later 

20  /20 
14/14 
Coma 

974     Jan.    20.  191(1                25 
24                             24 
Oft.      4                             24 
20                Coma 

1005 

Mar      (1    191(1 

23  /24 

19 
Coma 

April    4 
July      5 
Died  43  hours 
later 

99(1 
1120 

Feb.    1(1,  191(1 
21 
25 
27 
Mar.     1 

Oet.      13 

24 
24 

24 

Coma 

1007 

Jan.       5,  1910 

25 

1032 

April  15.  1910 

25 

1053 

May   15,  191(1 
1(1 
17 
is 
19 
20 
Died  14  hours 
later 

21 

22/19 
18/21 
15  '14  /14 
12/12 
1  1 
Coma 

1111       Sept.  1(1,  191(1 

23  ,25 

1  151      Oct.    30,  191(1 

25 

Sept.     (1,  191(1 
7 
11 
Oct.    11 
14 
27 
2S 
29 
Nov.     1 
2(1 

21 
is 
29 

20 
15/15 
24 

33 

Coma 

11  M       Nov.  10,  1910 

24 

119(1 

Dee.      S.  1910 
9 
10 
11 
12 
13 

21 
22  /24 
IS/20 
20 
21 
24 

1143 

(let.       7,       191(1 

Died  within 
21  hours 

14/12 
Coma 

1209 

Jan.       2,  1917 

24 

10.S5      Oct.    3d.  191(1                 20 
Nov.   1  5                 Inanition 

1214 

Dee.    30,   1910 

25 

7SO      Jan.     11,  191(1              IS/20 
12                            21 
1  ^                            25 
Mar.  31,   1917  'Tuberculosis  ? 

1220 

Jan.    23,  1917 

'A.M. 


2P.M. 


EXAMINATION  OF  THE  RESPIRATION 


235 


by  multiplying  by  the  difference  between  barometric  pressure  at 
the  time  of  the  test,  and  this  varies  in  Boston  between  770  mm., 
and  750  mm.,  and  the  tension  of  aqueous  vapor  at  37.5°  (\,  which 
is  48  mm.  mercury.  This  will  make  a  factor  which  lies  between 
722  and  702.  As  the  reading  of  700  is  much  the  more  common  at 


C 


sea  level,  for  clinical  purposes  the  factor  715  =*=  may  be  used  satis- 
factorily. The  patient  should  be  in  the  same  position  and  quiet 
for  ten  minutes  prior  to  the  performance  of  the  test. 

After  a  normal  inspiration  the  end  A  of  the  apparatus  is  in- 
serted between  the   lips   and   the   patient    is  instructed  to  expire 


230        I'RIXE,    BLOOD   AX  I)   ItEM'IHATIOX   IX    DIABETES 

forcibly  through  the  apparatus  Avith  cocks  ('  and  I)  open,  so  that 
there  is  a  free  passage  from  .1  to  li.  The  tube  remains  in  the 
mouth  throughout  the  entire  expiration,  and  the  cock  ('  is  then 
closed,  thus  retaining  between  cocks  ('  and  I)  the  last  100  c.c.  of 
expired  air.  (As  the  exchange  of  air  in  the  upper  respiratory 
passage  is  200  c.c.,  and  the  exchange  of  air  from  the  alveoli  isSOO 
c.c.,  it  is  plain  that  with  any  care  at  all  a  sample  of  alveolar  and 
not  upper  respiratory  air  will  be  obtained.)  The  apparatus  is  now 
immersed  in  a  glass  tank  of  water  at  room  temperature  and  allowed 
to  remain  there  five  minutes'.  The  best  way  to  obtain  water  at  room 
temperature  is  simply  to  keep  the  glass  tank  in  the  room  with  the 
patient  for  several  hours  before  the  test,  though  with  an  ordinary 
thermometer  one  can  easily  adjust  the  temperature  of  the  water 
to  that  of  the  room.  At  the  end  of  five  minutes  about  10  c.c.  of 
20  per  cent,  aqueous  solution  of  potassium  hydrate  are  poured  into 
the  apparatus  through  orifice  H.  A  little  of  this  potassium  hydrate 
will  leak  through  the  hole  in  cock  J)  to  chamber  ('-•]).  Now  cock 
I)  is  turned  to  the  left  so  that  chamber  ('•  I)  is  closed  and  chamber 
B-l)  is  also  closed.  The  small  amount  of  potassium  hydrate  in 
chamber  CD  is  shaken  in  the  chamber  for  a  moment.  Then  with 
apparatus  in  upright  position  cock  I)  is  turned  so  that  there  is  a 
continuous  passage  from  ('  and  />',  and  the  amount  of  potassium 
hydrate  which  will  run  into  the  chamber  ('  J)  is  allowed  to  do  so. 
Now  cock  J)  is  turned  to  the  left  until  B-])-E  is  a  continuous 
passage,  and  in  this  way  potassium  hydrate  is  allowed  to  escape 
into  the  water  tank.  Chamber  ('  J)  still  contains  2  or  )>  c.c.  of 
potassium  hydrate  solution,  and  should  be  thoroughly  washed  with 
this  solution.  F,very  point  in  the  surface  of  chamber  ('-])  must  be 
touched  by  the  alkaline  solution.  This  is  accomplished  by  shaking 
very  thoroughly  the  potassium  hydrate  in  chamber  C-J).  The 
apparatus  is  again  immersed  in  the  tank  of  water,  cock  I)  is  turned 
to  the  left  until  water  rises  into  ('  I)  through  E-D  (',  and  the 
apparatus  left  in  the  water  five  minutes.  At  the  end  of  this  time 
the  apparatus  is  raised  until  the  bottom  of  the  meniscus  of  the  water 
in  chamber  ('  D  is  level  with  the  top  of  the  water  in  the  tank. 
Xow  cock  1)  is  turned  to  the  right  until  water  runs  through  /.'  -D-B 
to  the  level  of  water  in  chamber  ('•  1),  which  is  now  closed.  Then 
cock  I)  is  turned  farther  to  the  right  until  ('  D  B  is  a  continuous 
chamber.  The  apparatus  is  then  again  immersed  to  the  bottom 
of  the  glass  tank  and  the  water  in  the  arm  />  I)  of  the  apparatus 
should  be  at  the  same  level  with  the  water  in  the  chamber  ('•  D 
and  continuous  with  it.  If  this  is  not  so,  then  the  amount  of  water 
in  />'  1)  should  be  changed  until  it  reaches  the  height  of  the  column 
of  water  in  ('  J).  The  reading  is  now  taken  in  cm.  of  the  height 
to  which  the  column  of  water  stands  in  ('--  J),  and  this  is  so  gradu- 


EXAMINATION  OF  THE  RESPIRATION  237 

ated  as  to  represent  the  percentage  of  CO2  which  was  absorbed  by 
alkali  and  replaced  by  water.  This  completes  the  test. 

The  apparatus  is  prepared  for  the  next  test  by  opening  cock  C 
so  that  A  to  B  is  a  continuous  passage.  The  fluid  in  the  apparatus 
is  allowed  to  escape.  Orifice  B  is  put  under  the  faucet  and  cold 
water  allowed  to  run  through  the  apparatus,  taking  care  to  shake 
sufficiently  at  the  time,  so  that  water  touches  all  of  the  inside  of 
the  apparatus.  Repeat.  Then  pour  through  orifice  B  about  10 
c.c.  of  4  per  cent,  solution  boric  acid.  Rinse  the  apparatus  very 
thoroughly  with  this  acid  so  that  there  shall  be  no  alkali  remaining 
adherent  to  its  sides.  Wash  again  with  cold  water.  Leave  the 
apparatus  so  that  the  cocks  to  .1  and  B  are  open,  thereby  allowing 
any  water  in  the  apparatus  to  drain  out. 

From  the  above  it  will  be  seen  that  the  apparatus  necessary  is, 
first,  the  Fridericia  appliance,1  a  glass  tank,  whose  depth  is  equal 
to  the  length  of  the  Fridericia  apparatus,  a  wash  bottle  containing 
20  per  cent,  solution  of  potassium  hydrate  and  another  wash  bottle 
containing  4  per  cent,  solution  of  boric  acid.  It  is  convenient  to 
add  an  indicator,  such  as  alizarin  or  litmus,  to  the  alkaline  and  acid 
fluids. 

(/;)  Marriott's  Method.2 — A  very  simple  method  has  been  devised  by 
Marriott  for  the  determination  of  the  CO2  in  the  alveolar  air.  The 
apparatus  is  portable  and  the  test  requires  but  a  few  moments  for 
execution.  Two  procedures  are  involved:  the  collection  of  the 
alveolar  air  and  the  analysis  of  the  sample. 

"Principle  of  the  Method  of  Analysis. — The  method  depends  on 
the  fact  that  if  a  current  of  air  containing  carbon  dioxide  is  passed 
through  a  solution  of  sodium  carbonate  or  bicarbonate  until  the 
solution  is  saturated,  the  final  solution  will  contain  sodium  bicar- 
bonate and  dissolved  carbon  dioxide.  The  reaction  of  such  a  solu- 
tion will  depend  on  the  relative  amounts  of  the  alkaline  bicarbonate 
and  the  acid  carbon  dioxide  present.  This,  in  turn,  will  depend  on 
the  tension  of  carbon  dioxide  in  the  air  with  which  the  mixture  has 
been  saturated  and  will  be  independent  of  the  volume  of  air  bloicn 
through,  provided  saturation  has  once  been  attained.  High  tensions 
of  carbon  dioxide  change  the  reaction  of  the  solution  toward  the 
acid  side.  Low  tensions  have  the  reverse  effect;  hence  the  reaction 
of  such  a  solution  is  a  measure  of  the  tension  of  carbon  dioxide  in 
the  air  with  which  it  has  been  saturated. 

"The  reaction  of  such  a  solution  may  be  determined  by  adding 
to  it  an  indicator  such  as  phenolsulphonephthalein,  which  shows 
over  a  considerable  range  of  reaction  definite  color  changes.  A 
certain  color  indicates  a  certain  reaction. 

'Apparatus  may  be  purchased  from  Emil  Grciner,  55   Fulton  Street,  New  York. 
2  Marriott:    Jour.  Am.  Med.  Assn.,  191G,  Ixvi,  p.  1594. 


238       URINE,   BLOOD  AND  RESPIRATION  IN  DIABETES 

"Solutions  of  a  given  reaction  may  be  prepared  by  mixing  acid 
and  alkaline  phosphates  in  definite  proportions.  Such  solution  may 
be  kept  unaltered  for  long  periods  of  time  and  can  be  used  as 
standards  for  comparison." 

"Collection  of  the  Alveolar  Air. — With  an  ordinary  atomizer  bulb, 
which  will  deliver  approximately  50  c.c.  of  air,  force  approximately 
(i(K)  c.c.  of  air  into  the  rubber  bag  and  clamp  the  outlet  tube  with  the 
pinch-cock.  While  the  subject  is  at  rest  and  breathing  naturally 
and  at  the  end  of  a  normal  expiration,  place  the  tube  in  the  subject's 
mouth  and  close  his  nose,  allowing  him  to  breathe  from  and  into  the 
bag  four  times  in  twenty  seconds,  emptying  the  bag  with  each 
inspiration;  the  observer  should  indicate  when  breathing  should 
be  in  or  out.  More  frequent  breathing  will  not  greatly  alter  the 
results.  After  breathing  twenty  seconds,  at  the  end  of  an  expira- 
tion and  while  the  bag  is  inflated,  clamp  the  tubing  with  the  pinch- 
cock  and  use  the  air  contained  in  the  bag  for  analysis.  The  analysis 
should  be  made  within  three  minutes,  as  carbon  dioxide  rapidly 
escapes  through  rubber. 

"In  the  case  of  comatose  patients,  the  rubber  bag  should  be  inflated 
with  approximately  1000  cubic  centimeters  of  air.  The  comatose 
patient  should  be  allowed  to  breathe  out  of  and  into  the  bag  for  at 
least  thirty  seconds,  since  it  is  not  feasible  to  have  him  completely 
empty  the  bag  of  air,  at  each  inspiration.  It  is  necessary  to  use 
some  form  of  mask. 

"A  mask  is  also  necessary  for  collecting  alveolar  air  from  infants 
and  comatose  patients.  This  may  be  improvised,  as  suggested  by 
Marriott,  by  means  of  a  nipple  of  a  wide-mouth  (Ilygeia)  nursing 
bottle  and  a  piece  of  thin  rubber  tissue  (dental  dam)." 

"Tcchnic  <f  Analysis. — I'ill  the  test-tube  one-fourth  full  with 
standard  bicarbonate  indicator  solution.  Then  place  the  capillary 
nox/le  tube  in  the  outlet  tube  of  the  bag  and,  by  releasing  the  pinch- 
cock,  allow  the  alveolar  air  from  the  bag  to  pass  rapidly  through 
the  solution  in  the  test-tube  for  about  one  minute  or  until  no  fur- 
ther color  changes  occur.  The  tube  is  then  stoppered  and  the  color 
immediately  compared  with  that  of  the  standard  solutions,  by 
placing  it  in  the  center  section  of  the  comparison  box  and  the 
standard  solutions  most  nearly  approaching  its  color  on  either  side. 
Examinations  should  be  made,  if  possible,  at  temperatures  from 
1:0  to  25°('.;  if  the  room  temperature  is  above  or  below  this,  the 
specimen  should  be  immersed  in  water  at  about  25°  ('.  while  being 
saturated  with  the  gas  being  examined." 

"  /iV.v////.v.  If  the  simple  conditions  described  above  for  the  col- 
lection and  analysis  of  air  samples  arc  complied  with,  duplicate 
determinations  usually  agree  within  2  nun.  More  than  one  deter- 
mination should  be  made  in  every  instance,  especially  in  confirma- 


EXAMINATION  OF  THE  RESPIRATION  239 

tion  of  a  low  tension,  since  errors  in  the  technic  of  collection  of  the 
sample  lead  to  too  low  rather  than  to  too  high  results.  In  the  ease 
of  failure  of  successive  determinations  to  agree,  the  fault  is  much 
more  likely  to  lie  in  the  collection  than  in  the  analysis  of  the  sample." 

In  normal  adults  at  rest,  the  carbon  dioxide  tension  in  the  alveolar 
air,  determined  as  described  above,  varies  from  40  to  45  mm. 
Tensions  between  30  and  of)  mm.  are  indicative  of  a  mild  degree 
of  acidosis.  When  the  tension  is  as  low  as  20  mm.,  the  individual 
may  be  considered  in  imminent  danger.  In  coma,  associated  with 
acidosis,  the  tension  may  be  as  low  as  8  or  10  mm.  In  infants,  the 
tension  of  carbon  dioxide  is  from  3  to  5  mm.  lower  than  in  adults. 

Conditions  other  than  acidosis  may  affect  the  carbon  dioxide 
tension.  Stimulation  of  the  respiratory  center  leads  to  increased 
pulmonary  ventilation  and  a  consequent  lowering  of  the  alveolar 
carbon  dioxide  tension.  Such  stimulation  may  be  brought  about  by 
caffein,  and  possibly  also  by  intracranial  lesions.  The  respiratory 
center  may  be  depressed  by  morphin,  and,  as  the  result  of  certain 
infections.  This  leads  to  an  increased  carbon  dioxide  tension. 
Changes  in  the  excitability  of  the  respiratory  center,  however,  are 
but  rarely  great  enough  to  affect  significantly  the  composition  of  the 
alveolar  air. 

"Alveolar"  air  collected  as  described  above,  is  essentially  air 
which  has  come  in  equilibrium  with  the  venous  blood  in  the  pul- 
monary capillaries.  The  tension  of  carbon  dioxide  is  approximately 
that  in  the  venous  blood.  "Alveolar"  air  collected  by  the  Ilaldane 
or  Fridericia  methods  is  air  which  has  come  in  approximate  equi- 
librium with  the  arterial  blood,  and  hence  is  of  a  carbon  dioxide 
tension  from  10  to  20  per  cent,  lower. 

Changes  in  the  pulmonary  epithelium  such  as  would  prevent  the 
air  in  the  lungs  from  coming  in  equilibrium  with  the  blood  in  the 
capillaries  would,  of  necessity,  affect  the  composition  of  the  alveolar 
air.  Since  very  little  is  known  as  yet  regarding  the  exact  effect  of 
such  changes,  one  is  hardly  justified  in  drawing  conclusions  regard- 
ing acidosis  from  the  composition  of  the  alveolar  air  in  patients  with 
pulmonary  affections.  Case  No.  1239,  p.  443,  is  an  excellent  illus- 
tration of  this  point. 


SECTION    IV. 
THE  DIET  IX  HEALTH  AM)  IX  DIABETES. 

A.    THE  DIET  OF  NORMAL  INDIVIDUALS. 

1.  Caloric  Needs  of  the  Body. — The  diet  of  normal  individuals 
varies  greatly,  but  a  normal  ration  for  a  man  weighing  70  kilograms 
(lf)4  pounds)  when  at  moderate  work  would  contain  approximately 
2(S()()  calories,  but  if  he  weighed  00  kilograms  (Io2  pounds),  2-100 
calories,  or  40  calories  per  kilogram  body  weight.  Individuals  with 
sedentary  occupations  require  far  less  and  I  agree  with  Chittenden 
about  2100  calories,  or  .'50  calories  per  kilogram  body  weight.  15y 
a  calorie  is  understood  the  amount  of  heat  necessary  to  raise  the 
temperature  of  one  kilogram  of  water  1°  (\,  or  what  is  approxi- 
mately the  same  thing,  one  pound  of  water  4°  F.1  The  heat  liberated 
by  one  gram  of  the  various  foodstuffs  during  their  combustion  in  the 
body  is  shown  in  the  following  table.  In  clinical  diabetic  com- 
putations the  decimals  may  be  omitted: 

TAKLK   lO'.t. — CALORIC  YALI'KS  OF  FOODS. 
1  gram.  Calorics.  Calories. 

Carbohydrate 4  actually             4.1 

Protein 4  4.1 

Fat 0  "                   0.3 

Alcohol 7  7.1 

The  caloric  needs  of  the  body  vary  not  only  from  day  to  day  and 
hour  to  hour,  but  from  moment  to  moment.  It  is  convenient  to 
remember  that  one  calorie  per  kilogram  body  weight  per  hour  was 
eliminated  by  a  group  of  normal  individuals  at  the  Nutrition 
Laboratory,  while  in  bed,  and  1.21  calories  JXT  kilogram  per  hour 
were  eliminated  while  sitting  in  a  chair.  In  other  words,  20  per 
cent,  more  energy  was  required  by  these  individuals  to  sit  in  a 
chair  than  to  lie  on  a  couch.  If  the  subject  is  asleep  lying  down 
and  awake  sitting  up,  the  difference  may  be  )>;")  to  40  per  cent.  On 
the  other  hand,  if  the  greatest  possible  care  is  taken  to  be  as  quiet 

1  This  is  a  larw  caloric,  often  written  with  a  capital  (';  a  small  caloric  deals  with 
1  ^nnii  instead  of  1  kilogram. 

( 240 ) 


THE  DIET  OF  NORMAL  INDIVIDUALS  241 

when  erect  as  horizontal,  the  difference  may  be  only  8  per  cent. 
If  the  individual  is  in  a  comfortable  steamer  chair  or  propped  up 
in  a  semireclining  position  with  a  back  rest,  the  metabolism  is 
3  per  cent,  less  than  when  lying  flat  in  bed.1  At  the  Nutrition 
Laboratory  89  normal  men  eliminated  on  the  average  25.5  calories 
at  rest  per  kilo  body  weight  per  twenty-four  hours,  as  calculated 
from  the  oxygen  or  carbon  dioxide,  the  total  output  per  twenty-four 
hours  being  1009  calories,  and  08  normal  women  eliminated  on 
the  average  24.9  calories,  calculated  per  kilogram  of  body  weight 
per  twenty-four  hours,  a  total  output  of  1355  calories  for  the  twenty- 
four  hours  of  the  day.  Too  often  in  dietetic  computations  it  is 
assumed  that  the  caloric  needs  of  the  body  can  be  accurately  esti- 
mated. As  a  matter  of  fact,  the  error  in  such  computations  is  con- 
siderable, and  it  is  absurd  to  expect  to  compute  the  needs  of  the 
individual  when  up  and  about,  whether  normal  or  diabetic,  more 
closely  than  within  10  to  20  per  cent,  of  the  real  value. 

As  an  illustration  of  the  amount  of  work  which  can  be  performed 
by  1  calorie  of  energy,  I  learn  from  my  friend,  Professor  Benedict, 
that  the  expenditure  of  1  calorie  of  heat  is  required  to  rise  from 
a  sitting  position  in  front  of  a  door,  turn  the  key  in  the  door,  and 
sit  down.  A  single  sixteen  candle-power  carbon  lamp  gives  off  in 
heat  the  equivalent  of  about  45  calories  per  hour. 

To  walk  one  hour  on  a  level  road  at  the  rate  of  2.7  miles  an  hour 
requires  100  calories  above  that  of  the  resting  metabolism  (Lusk). 
The  amount  of  energy  expended  in  walking  on  a  level  road  can  be 
calculated  with  more  accuracy  as  follows:  If  the  individual  weighs 
00  kilograms  and  walks  1000  meters  (3281  feet)  he  is  said  to  have 
travelled  (00  X  1000)  00,000  horizontal  kilogram-meters.  For 
each  horizontal  kilogram-meter  0.0005  calories  are  required.  This 
would  represent  an  expenditure  of  (60,000  X  0.0005)  30  calories, 
which  should  be  added  to  the  resting  metabolism  of  the  individual 
during  the  time  required  to  walk  the  given  distance.  A  man  weigh- 
ing 60  kilograms  who  walks  four  miles  an  hour  would  expend 
(60  (kilograms)  X  4  (miles)  X  1009.3  (meters  in  1  mile)  X  0.0005 
(calories  per  horizontal  kilogram-meter))  193  calories.  To  this 
figure  should  be  added  60  calories,  on  the  basis  of  1  calorie  per 
kilogram  body  weight  per  hour,  which  would  have  been  expended 
by  the  individual  at  rest  if  one  desires  to  obtain  the  total  expendi- 
ture of  heat.  The  basis  for  calculations  of  this  type  is  direct 
measurement.  It  should  be  remembered  that  the  weight — 60  kilo- 
grams— represents  the  naked  weight  of  the  individual  plus  the  weight 
of  his  clothes.  If  a  pack  weighing  5  kilograms  is  carried,  then  the 
calculations  must  be  on  the  basis  of  65  kilograms. 

1  Sonderstrom,  Meyer  and  DuBois:    Arch.  Int.  Mod.,  1910,  xvii,  p.  872. 
16 


242  DIET  IX  HEALTH  AXD  IX  DIABETES 

If  the  individual  ascends  a  height,  the  calculations  are  somewhat 
dill'erent.  The  unit  is  the  vertical  kilogram-meter.  The  weight 
of  an  individual  in  kilograms  multiplied  by  the  height  ascended  in 
meters  gives  the  vertical  kilogram-meters.  The  heat  equivalent 
of  the  mechanical  work  evolved  in  420.5  vertical  kilogram-meters  is 
1  calorie.  Thus,  if  an  individual  of  00  kilograms  body  weight 
walks  up  ten  flights  of  stairs  each  o  meters  high,  he  would  expend 

(GO  X  10  X  :->)  '  ,  .    . 

.  _  4.2  calories.     As  the  mechanical   emeiencv  or   the 

42o.o 

body  is  only  about  20  per  cent.,  it  is  necessary  to  multiply  this 
figure  by  5  in  order  to  determine  the  actual  energy  expended 
(4.2  X  •">)  namely,  21  calories.  Here  we  are  dealing  with  figures 
based  on  estimate  and  not  on  direct  experimentation.  To  this  figure 
must  be  added  the  calories  necessary  for  horizontal  progression, 
as  well  as  the  calories  required  during  the  same  period  of  resting 
metabolism.  Two  calorics  might  therefore  l>e  added  for  the  forward 
progression,  and  '•>  calorics  more  for  the  three  minutes  of  time  of 
resting  metabolism.  In  other  words,  a  man  of  00  kilograms  walking 
up  ten  flights  of  stairs  each  o  meters  (10  feet)  high,  in  three  minutes 
would  expend  the  heat  equivalent  of  20  calories  or  about  .'5  calories 
IXT  flight. 

The  basal  metabolism  of  a  fasting  individual  weighing  00  kilo- 
grams (l.'!2  pounds)  has  been  determined  by  Benedict  (see  pp.  150 
and  151)  and  found  to  vary  between  1845  and  1318  calories  during 
the  thirty-one  days  of  the  fast. 

It  has  been  estimated  that  an  individual  weighing  70  kilograms 
(154  pounds)  requires,  under  the  varying  conditions  set  forth  in 
Table  110,  the  given  number  of  calories: 


TABU:   110.  —  CALI/UIKS   Ri;o.riKKi>  DTKIM;  TWKNTY-KOUR    Horns  HY   AX 
Anri/r  \Yi-:i<;m\<;  70   KILOGRAMS  (lot   POUNDS). 


(  'oiidilioii. 

At  rest     .......  2:>-:>()  11-14  17.->0-21()0 

Liiiht  work   ......  3.V10  1<)-1S  24nO-2SOO 

Mode-rate  work        ....  -lO-lo  1S-20  2X00^150 

Hard  work    ......  l.Vf.O  2027  :UoO-4200 

Farmers  in  various  parts  of  the  I  mted  States  have  been  shown 
to  consume  on  an  average  ;>500  calorics. 

The  total  metabolism  of  individuals  lias  usually  been  reckoned 
per  kilogram  body  weight,  no  standard  for  comparison  of  the 
metabolism  according  to  body  surface  having  been  generally 
accepted.  Recently  I  HiBois  has  constructed  two  formula.',  the  linear 
formula  and  the  height  and  weight  formula,  by  which  it  is  possible 


THE  DIET  OF  NORMAL  INDIVIDUALS  243 

very  conveniently  and  accurately  to  make  such  comparisons.1 
Means2  has  confirmed  their  work.  Below  is  given  the  table  of 
Gephart  and  DuBois.  According  to  their  formula,  40  calories  per 
square  meter  per  hour  represents  the  metabolism  of  normal  men, 
and  37  calories  that  of  women.  The  average  metabolism  of  fat  and 
thin  subjects  is  the  same  according  to  surface  area  when  the  surface 
area  is  correctly  measured. 

TABLE  111. — STANDARDS  OF  NORMAL  METABOLISM.     AVERAGE  CALORIES  PER 
HOUR  PER  SQUARE  METER  OF  BODY  SURFACE. 

According  to 

linear  and 

Age  in  height-weight 

Subjects.  years.  formulas. 

Boys 12  to  13  49.9 

Men 20  to  50  39 . 7 

Women 20  to  50  36 . 9 

Men 50  to  60 

Women 50  to  60 

Normal  boys  twelve  or  thirteen  years  of  age  have  been  shown  by 
DuBois3  to  produce  25  per  cent,  more  heat  than  adults  when  com- 
pared according  to  his  linear  formula  of  body  surface.  Recently 
Gephart4  in  a  study  of  the  dietary  at  St.  Paul's  School  came  to  the 
conclusion  that  the  boys  whose  average  ages  fell  between  thirteen 
years  and  six  months  and  sixteen  years  and  one  month  ate  approx- 
imately 5000  calories  daily.  For  these  same  boys,  the  calculated 
basal  metabolism  would  amount  to  about  1700  calories.  It  is  there- 
fore evident  that  children  require  proportionately  more  food  per 
kilogram  or  pound  body  weight,  and  I  have  endeavored  to  allow 
for  this  in  the  following  empirical  table: 

TABLE  112. — CALORIC  NEEDS  OF  CHILDREN  DURING  TWENTY-FOUR  HOURS. 

Age  in  Weight.  Calories,  Total 

years.  kg.  pounds.  kg.  pounds.  calories. 

2 12     26       80     36       960 

6 20     44       70      31       1400 

12 36     SO       50     23      1800 

2.  Composition  of  the  Diet. — The  ordinary  diet  for  a  man  at 
moderate  work  would  contain  about  400  grams  of  carbohydrate, 
100  grams  of  protein  (equivalent  to  16  grams  of  nitrogen,  approx- 
imately eliminated  as  14  grams  in  the  urine  and  2  in  the  feces)  and 
100  grams  of  fat.  This  would  amount  to  2900  calories  in  the  twenty- 

1  Gephart  and  DuBois:  Arch.  Int.  Med.,  1910,  xvii.  p.  902. 

2  Means:  Arch.  Int.  Med.,  1916,  xxi,  p.  2G3. 

3  DuBois:  Arch.  Int.  Med.,  1916,  xvii,  p.  887. 

4  Gephart:  Boston  Med.  and  Surg.  Jour.,  1917,  clxxvi,  p.  17. 


244 


DIET  IN  HEALTH  AND  IN   DIABETES 


four  hours,  or  about  40  calories  per  kilo  for  an  individual  weighing 
70  kilograms.  These  figures  would  be  proportionately  reduced 
both  for  those  of  lower  body  weight  and  for  those  with  lighter 
occupations,  who  would  require  nearer  )>0  calories  per  kilo.  As 
age  advances  the  metabolic  requirements  are  lessened,  thus  if  12000 
calories  are  required  at  thirty  years,  1800  calories  will  suffice  at 
seventy  and  .1000  at  eighty  years  of  age. 

TAHLI:    llo. — Tin-:   I'ltoroirnox  OF  CAUBOHYDKATK,    PKOTKIN   AND  I-'AT  IN 
TIIK  NORMAL   DIKT. 


Quantity, 

Calorics, 

Total 

Food. 

grams. 

per  gram. 

calorics. 

Carbohydrate    . 

.        .        .        .       400 

4 

1600 

Protein    

.        .        .        .        100 

4 

400 

Fat 

100 

1) 

900 

The  figures  given  above  are  very  different  from  the  old  Yoit 
standard  in  which  the  carbohydrate  was  placed  at  500  grains,  the 
protein  at  125  grains  and  the  fat  at  55  grams.  The  more  I  observe 
the  diets  of  non-diabetic  patients,  the  more  I  have  come  to  believe 
that  adults  eat  less  than  has  generally  been  supposed. 

Chittenden,1  in  his  painstaking  and  scientific  manner,  accom- 
plished an  immense  amount  of  good  when  he  showed  that  people 
ordinarily  consumed  much  more  food  than  physiological  needs 
demand.  lie  suggests  that  it  is  more  than,  probable  that  this 
excess  of  food  is  in  the  long  run  detrimental  to  health,  weakening 
rather  than  strengthening  the  body  and  defeating  the  very  object 
of  nutrition. 

?•>.  Carbohydrate.—  From  the  preceding  statements  it  will  be  seen 
that  55  per  cent,  of  the  energy  of  the  diet  of  the  normal  '.ndividual 
consists  of  carbohydrate.  These  figures  are  only  approximate,  but 
they  leave  no  doubt  as  to  how  large  a  place  sugar  and  starch  occupy 
in  the  daily  ration  (see  p.  50). 

The  accompanying  illustration  shows  graphically  the  relative 
caloric  value  of  the  different  foodstuffs  in  the  total  diet. 


The  normal  diet, 


Kic.   10. — The  relative  calorie,  value  of  protein,  carbohydrate,  and  fat 
in  a  normal  diet . 


1  Chittenden:  Physiological  Economy  in  Nutrition,  New  York,  1904,  p.  474. 


THE  DIET  OF  NORMAL  INDIVIDUALS  245 

The  proportion  of  carbohydrate  in  the  normal  diet  varies  in 
different  countries,  reaching  its  maximum  in  the  tropics  and  its 
minimum  in  the  arctic  zones.  The  people  in  India  take  484  grams 
carbohydrate,  while  the  Eskimos  get  along  very  comfortably  upon 
52  grams.  I  have  arranged  Table  114  modifying  somewhat  a 
similar  table  of  Lusk's.1  It  shows  well  the  adaptability  of  different 
races  to  different  diets.  That  the  Eskimos  live  upon  52  grams  of 
carbohydrate  daily  should  greatly  encourage  diabetic  patients. 
All  who  treat  diabetics  should  be  very  thankful  that  there  is  a  race 
of  Eskimos  through  which  proof  is  afforded  that  it  is  perfectly 
possible  to  maintain  life  on  a  diet  in  which  carbohydrate  is  largely 
replaced  by  fat.2 

TABLE  114. — VARIATIONS  IN  DIET  ACCORDING  TO  RACE. 

Weight,  Protein,      Carbohydrate,  Fat,  Total 

Rare.  kilos.  gm.  gm.  gin.  calories. 

Eskimo        .      .      .  Go  2S2  52  141  2004 

Bengali       .      .      .  50  52  484  27  2390 

European    ...  70  118  512  (>5  3055 

American3  ...  70  100  400  100  2900 

The  composition  of  the  diet  also  varies  in  the  same  race  from 
time  to  time  and  this  has  been  interestingly  described  by  Mendel.4 
Attention  has  already  been  called  to  the  increase  in  the  consumption 
of  sugar  in  the  United  States  during  the  last  century.  Rubner 
noted  that  the  consumption  of  meat  per  capita  in  Germany  had 
risen  three  and  one-half  times  during  a  hundred  years. 

4.  Protein. — The  quantity  of  protein  in  the  normal  diet  is 
probably  not  far  from  100  grams. 

Professor  Cannon  writes  me  that  he  has  "reports  from  40  different 
students  who  have  lived  carefully  and  made  thorough  reports  of 
their  conditions  during  four  days,  on  the  last  of  which  unusual 
exercise  was  taken.  The  average  excretion  of  nitrogen  for  these 
46  students,  on  the  four  days  in  succession,  was  12,  12.10,  12.88 
and  12.29  grams."  If  we  raise  the  nitrogen  to  14  grams  by  allowing 
the  difference  for  that  eliminated  in  the  feces,  the  total  elimina- 
tion of  nitrogen  would  be  14  grams,  and  this  would  represent  the 
equivalent  of  88  grams  protein  (14  X  0.25  =  <88)  as  the  normal 
metabolism  of  these  students.  It  will  be  found  of  great  advantage 
to  accustom  oneself  to  estimate  the  protein  content  of  the  diet  of 

1  Lusk:The  Fundamental  Basis  of  Nutrition,  Yule  Univ.  Press,  1914,  p.  31. 

2  It  must  be  acknowledged,  however,  that  today  the  Danish  Government  supplies 
the  Eskimo  with  more  than  this  quantity  of  carbohydrate.     Krogh:    A  Study  of  the 
Diet  and  Metabolism  of  Eskimos,  Copenhagen,  1913. 

3  Added  by  E.  P.  .1. 

•'Mendel:  Changes  in  the  Food  Supply  and  Their  Relation  to  Nutrition,  Xe\v 
Haven,  Yale  University  Press,  1916. 


246  DIET  IX  HEALTH  AXD  IX   DIABETES 

patients  in  terms  of  nitrogen  as  well  as  in  piotein,  and  to  control 
one's  calculations  by  determining  the  nitrogen  in  the  urine.  Such 
controls,  however,  will  not  be  of  value  if  the  patient  is  undergoing 
rapid  changes  of  diet  or  weight. 

Y\  hen  Professor  ( 'hittendeii's1  epoch-making  studies  appeared, 
many  felt  that  he  went  to  extremes,  but  today  his  statements  appear 
very  moderate.  He  wrote  "Food  requirements  must  with  necessity 
vary  with  changing  conditions  .  .  .  all  the  results  so  far 
obtained  in  this  investigation  with  a  great  variety  of  persons  point 
to  the  conclusion  that  the  real  demands  of  the  body  for  protein  food 
do  not  exceed  .">()  per  cent,  of  the  amount  generally  consumed. 
Half  of  the  IIS  grams  of  protein  food  called  for  daily  in  ordinary 
dietary  standards  is  quite  sufficient  to  meet  all  the  real  physiological 
needs  of  the  body.  .  .  ."  Instead  of  a  standard  of  IKS  grams 
protein  today,  100  grams  is  the  commonly  accepted  American 
standard.  Cannon's  students  ate  only  about  X8  grams.  All  in  all 
our  only  retort  to  the  New  Haven  Scientist  can  be  that  we  were 
really  rather  more  temperate  than  he  thought  (save  for  those  boys 
at  St.  Paul's  School),  and  we  will  all  agree  "excess  means  waste, 
but  of  far  greater  importance  is  the  unnecessary  strain  placed  upon 
the  body  by  this  uncalled-for  excess  of  food  materials  which  must 
be  gotten  rid  of  by  the  expense  of  energy  which  might  better  be 
conserved  for  more  useful  purposes." 

The  term  protein  is  a  broad  one,  and  until  recent  years  in  dietary 
programs  comparatively  little  account  has  been  taken  of  its  com- 
ponents. The  old  formula  for  hemoglobin — rrosH^o.'iOassNigsFeSg+T' 
—though  by  no  means  accurate,  gives  some  idea  of  its  complexity. 
The  individual  nitrogenous  substances  (amino- acids)  which  are 
found  in  protein  are  seventeen  in  number,  and  the  different 
proteins  vary  in  the  percentages  of  each  of  these  present.  The 
complete  proteins—  namely,  those  which  are  essential  for  constructing 
the  different  parts  of  the  body  contain  the  same  amino-acids  and 
such  proteins  are  represented  by  milk,  meat,  fish,  and  egg  proteins. 
In  gelatin  and  some  vegetable  foods,  important  amino-acids  are 
lacking  and  it  is  therefore  important  that  such  incomplete  proteins 
be  not.  furnished  diabetic  patients,  particularly  children,  when  on 
a  lo\v  diet.  Osborne  and  Mendel2  have  carefully  studied  the  value 
which  various  proteins  exercised  upon  growth  and  have  shown  that 
whereas  upon  milk  or  a  mixed  diet  young  rats  grew  normally,  if  a 
single  incomplete  protein  gliadin  was  given,  they  appeared  well, 
but  remained  dwarfs,  but  resumed  normal  growth  when  returned 
to  milk  or  mixed  diet. 

1  ( 'hit  tiMidon:  I. <><•.  cit .,  p.    17.~>. 

2<)sl)oriio  and  Mendel :  .lour,  of  Biol.  ('horn.,  1913.  xv,  p.  '.'>[  1 ;  1!»1."),  xxiii,  p.  439; 
1911),  xxiv,  p.  37;  191!'..  xxv,  p.  1;  191(>,  xxvi,  pp.  1  and  293. 


THE   DIET  OF   NORMAL   INDIVIDUALS  247 

The  quantity  of  protein  necessary  to  keep  in  nitrogenous  equilib- 
rium lias  been  found  by  Thomas1  to  vary  according  to  the  source. 

TAHI.K  11"). — RKI.ATIVK  QUANTITIES  OK  PROTEIN  RKQUIKKI)  TO  MAINTAIN 
NITROGENOUS  KQUILTHKITM. 

Protein.  (Jni. 

Meat   .  38 

Milk :il 

Rice 

Indian  corn 
Potato 
Bean    . 
Bread 

Furthermore,  a  ])ossibility  exists  that  protein  may  be  formed  in  the 
body  from  the  addition  of  nitrogen  to  the  decomposition  products 
of  sugar  (methyl-glyoxal,  lactic  acid,  pyruvic  acid)  in  the  form  of 
alanin. 

5.  Fat. — The  quantity  of  fat  in  the  normal  diet  varies,  partly 
from  choice  and  partly  from  economic  reasons.  In  general,  in 
those  cases  where  the  carbohydrate  in  the  diet  is  high,  the  fat  is 
low,  and  vice  versa.  The  Yoit  standard  placed  the  fat  at  55  grams, 
but  a  series  of  1MOO  dietary  studies  of  families,  carried  out  among 
different  races  and  in  different  countries,  showed  that  the  average 
quantity  of  fat  eaten  was  about  K>5  grams  (4.5  ounces)  per.  person 
per  day,  the  variation  recorded  being  from  45  to  390  grams  per 
person  per  day.2 

The  more  agreeable  varieties  of  fat,  such  as  butter,  cream  and 
oil,  are  expensive  foods.  Fat  is  also  a  concentrated  food,  not  only 
because  it  has  twice  the  caloric  value  of  either  carbohydrate  or 
protein,  but  because  it  occurs  more  frequently  in  pure  form.  Oil, 
butter,  and  lard  contain  little  water,  whereas  except  for  pure  sugar 
and  starch  most  carbohydrates  and  proteins  are  diluted  five  to  ten 
times  with  water. 

The  chief  source  of  error  in  calculating  the  total  caloric  value  of 
the  diet  and  especially  of  the  diabetic  diet  is  in  the  estimation  of 
fat.  Thus  for  many  years  I  have  considered  that  on  an  average 
lean  meat  and  fish  contained  10  per  cent,  fat  and  have  taught 
patients  to  reckon  •>  grams  of  fat  to  each  ounce  of  meat  or  fish.  This 
figure  is  unquestionably  correct  for  poultry  and  very  lean  meat,  and 
is  very  high  for  most  varieties  of  fish,  such  varieties  as  cod,  haddock 
and  flounder  containing  only  1  per  cent.,  but  an  analysis  of  a  mixture 
of  ten  portions  of  cooked  meat  exactly  identical  with  similar  por- 
tions about  to  be  served  patients  at  the  New  England  Deaconess 
Hospital  was  made  at  the  Nutrition  Laboratory,  and  showed  14.4 

1  Cited  l>y  Lusk,  lor.  cit.,  p.  20. 

2  Holmes  and  Lang:     Fats  and  Their  Economical   I ~se  in  the  Home,   I  .  >.   Dept. 
Agriculture,   191G,  Bull.  No.  4G9. 


24S 


DIET  IN  HEALTH  AND  IN  DIABETES 


per  cent.  fat.    It  is  therefore  better  to  reckon  five  grams  of  fat  to 
the  ounce  of  meat  when  the  patient  is  taking  several  varieties. 

Bacon  is  variously  estimated,  but  I  have  adopted  50  per  cent, 
as  an  average  value  for  the  fat  in  cooked  bacon.  Analyses  from 
different  sources  show  the  fat  of  cooked  bacon  varies  from  87  to 
7!)  per  cent.  Portions  of  bacon  lose  varying  quantities  of  weight 
in  the  cooking,  as  shown  in  the  following  table: 


TABLK   lit). — Loss  OF  WKKJHT  OF  BACO.V  mnuN<;  COOKING. 

Uncooked,  Cooked,  Loss, 

grains.  grams.  grams.  per  cent. 

SO  46  34  43 

200  100  100  50 

f>0  17  33  60 


60 
30 


23 
10 


37 
20 


62 
67 


Through  the  courtesy  of  Miss  Katherine  Blunt,  I  am  able  to 
insert  an  extensive  series  of  analyses  of  bacon.  These  make  it  very 
evident  that  our  caloric  values  for  bacon  must  be  very  crude  unless 
all  the  fat  in  the  frying  pan  is  utilized.  The  protein  appears  to  vary 
even  more  than  the  fat  in  the  cooked  bacon.  Figures  like  these 
upset  our  preconceived  ideas  about  dietary  values  and  show  the 
necessity  of  carefully  arranged  dietary  studies  upon  diabetic  patients. 

TABLK   117. — KFFKCT  OF  COOKING  UPON  VARIOUS   KINDS  OF  BACO.V 
(IVATHEHINK  BLUNT). 


Kind  of  bacon. 

Before 

cooking. 

After 
cooking 
little  to 

Loss   in 
little  to 

cooking 
medium. 

After 
cooking 

Loss  in   cooking 
much. 

medium. 

grams. 

grams. 

grams. 

per  cent. 

grams. 

grams. 

per  cent. 

114 

771 

38 

332 

301 

85 

74 

Rat  her  lean         .     •          105              5!)                40 

44              30'             76 

72 

11(1              55                55 

50 

— 

74 
101 
45 
47 


Very  fat   (special 


1  Returned  to  pan  after  weighing  and  cooked  much. 


83 

84 

1 87  87 

2  Very  little  cooked. 


Loss  on 

Fat, 

Protein, 

Ash, 

Water, 

cooking, 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

per  cent. 

61.9 

30.3 

7.7 

0  .  3 

82 

64.5 

28.1 

6.2 

0.3 

79 

71.4 

21.8 

2.7 

1.9 

65 

75.2 

18.5 

2.G 

69 

80.3 

12.0 

2.1 

2.8 

58 

THE  DIET  OF  NORMAL  INDIVIDUALS  249 

TABLE  118. — COMPOSITION  OF  VEIIY  FAT  BACON  COOKED  (KATHEHINE  BLUNT). 


Much  cooked 
Lightly  cooked 


Eggs  in  some  cities  by  law  must  weigh  a  pound  and  a  half  a 
dozen,  an  average  of  GO  grams  (2  ounces)  apiece.  Such  eggs  contain 
approximately  G  grams  of  protein  and  G  grams  of  fat.  The  German 
tables  generally  figure  the  fat  at  5  or  5-|  grams.  How  gross  our 
caloric  reckonings  are  is  obvious  if  a  collection  of  eggs  is  weighed  and 
the  minimum  and  maximum  weights  noted.  The  weight  of  the 
heaviest  egg  was  72  per  cent,  more  than  that  of  the  lightest.  (See 
Table  119.) 

TABLE  119. — VARIATIONS  IN  WEIGHTS  OF  ECHJS  WITH  THE  SHELLS. 


Number  eggs 
weighed. 

9 

Minimum, 
grams. 

52 

Maximum, 
grams. 

63 

Variation, 
per  cent. 

21 

12              .... 

40 

62 

55 

11  

56 

63 

12 

12         

51 

69 

35 

12  . 

48 

66 

38 

The  weight  of  egg  shells  is  usually  about  7  grams. 

These  examples  will  serve  to  show  that  doctors,  nurses  and 
patients  should  not  take  their  dietetic  calculations  of  calories  too 
seriously,  and  that  carbohydrate,  protein,  fat  and  calories  should 
not  be  recorded  in  decimals. 

G.  Caloric  Values  which  Every  Doctor  Should  Know  by  Heart.— 
The  quantity  of  carbohydrate,  protein  and  fat  found  in  an  ordinary 
diet  must  be  known  by  a  physician  if  he  wishes  to  treat  a  case  of 
diabetes  in  modern  fashion.  If  he  cannot  calculate  the  diet  he 
will  lose  the  respect  of  his  patient.  The  value  of  the  different 
foods  in  the  diet  can  easily  be  calculated  from  the  diet  Table 
120.  This  is  purposely  simple,  because  a  diet  chart,  to  be  useful, 
must  be  easily  remembered.  With  these  food  values  as  a  basis  it 
is  possible  to  give  a  rough  estimate  of  the  value  and  composition 
of  almost  any  food.  Various  foods  are  also  classified  according 
to  the  content  of  carbohydrate  (see  page  2GO)  in  f),  10,  15  and  20 
per  cent,  groups,  and  the  lists  are  so  arranged  that  those  first  in  the 
group  contain  the  least,  those  at  the  end  the  most.  This  is  a  practi- 
cal and  sufficiently  accurate  arrangement,  because  except  in  the  most 
exact  experiments  the  errors  in  the  preparation  of  the  food  are  too 
great  to  warrant  closer  reckoning.  It  is  practically  impossible 
except  when  accurate  analyses  of  the  diet  are  made  to  reckon  the 


250 


DIET  IN  HEALTH   AND  IN  DIABETES 


carbohydrate  for  the  twenty-four  hours  closer  than  within  5  to  10 
grains,  and  we  had  best  acknowledge  that  fact.  It  is  really  surpris- 
ing, however,  how  reliable  the  figures  are  if  we  do  not  push  the 
matter  to  extremes.  For  example,  the  protein  in  the  diet  of  one  of 
my  patients  at  the  Xew  England  Deaconess  Hospital,  as  recorded 
by  the  nurses  on  the  chart,  was  calculated  to  contain  10  grams  of 
nitrogen,  and  of  similar  portions  of  the  same  food  at  the  Nutrition 
Laboratory  by  analyses  17  grams  of  nitrogen  were  found.  On 
another  occasion  the  protein  was  analyzed  in  10  portions  of  cooked 
lean  meat,  similar  to  10  other  portions  served  the  same  day  at  the 
New  England  Deaconess  Hospital.  In  these  analyses  it  was  found 
that  the  protein  content  was  30  per  cent. 

TAHLE  120. — FOOD  YAI/TKS  IMPORTANT  i\  TI:E  TREATMENT  OK  DIAI:ETES. 


30  grams  (1  <>z.).                Carbohydrates, 

Protein, 

Pat, 

Contain  approximately 

grams. 

grams. 

gramt 

Oatmeal,  dry  weight 

20 

,") 

2 

Cream.  40%  

1 

1 

12 

(  'ream,  20'  ',   

1 

1 

G 

Milk    .      

l.o 

1 

1 

Brazil  nuts     

2 

.") 

20 

Oysters,  six     

4 

G 

1 

Meat  (uncooked,  lean)  . 

0 

(I 

3 

Meat  (cooked,  lean) 

0 

s 

5 

Bacon        

0 

5 

15 

Egg  (one)        .      .      .      . 

0 

(I 

6 

Vegetables,  ii'  (  group    . 

1 

()..') 

0 

Vegetables,  10'  ''(.  group 

2 

o  .  5 

0 

Potato       .       .       .       .       .       . 

(I 

i 

0 

Bread        

IS 

3 

0 

Butter       .             .... 

0 

0 

25 

Fish,  cod,  haddock  (cooked) 

0 

6 

0 

Broth        

0 

0.7 

0 

Small  orange  or  \  grapefruit 

10 

0 

0 

1  gram  protein,1  4  calories. 

1      "      carbohydrate,  4        " 
1      "      fat,  9 

1      "     alcohol,  7        " 

(i. 2")  grains  protein  contain  1  gram 
nitrogen. 


1  kilogram  =  2.2  pounds. 

.'50  grams  (gin.)  or  cubic  centi- 
meters ((!.('.)  =  1  ounce. 

A  patient  at  rest  requires  25  cal- 
ories per  kilogram  body  weight. 


ras.— Repeatedly  physicians  have  requested  me 
to  arrange  the  above  table  in  terms  of  household  measures.  To  a 
considerable  extent  this  is  impracticable  because  the  diabetic  diet 
deals  with  so  small  a  quantity  of  carbohydrate.  An  earnest  attempt 
to  do  this  has  been  made,  using  the  sensible  table  arranged  for 
general  food  values  by  F.  W.  White,-  and  tin1  100-calorie  portions 
so  much  in  vogue  and  described  in  the  excellent  book  of  Rose;1  but 

'These  equivalents  arc   not    exact    and   must    not    lie  omployr 
(Sec  Table  207,   pane  47_'.) 

-  Food  Values  in  ll»u-.chold  Measures.      F.  II.  Thomas  Co., 
3  Hose:  Feeding  the  Family.      The  MacMillan  Co.,  1<>1I>,  p.  K 


THE  DIET  OF  DIABETIC  INDIVIDUALS  251 

without  success.  The  only  safe  way  for  diabetic  patients  at  the 
commencement  of  their  training  is  to  weigh  their  food.  After  a  few 
days  of  weighing,  patients  can  select  utensils  which  conform  to  the 
size  of  the  portions  of  their  own  special  diets  and  use  these  exclusively. 
Fig.  11  shows  types  of  diabetic  crockery,  suggested  by  Miss  O'Reilly, 
a  visiting  nurse  to  the  New  England  Deaconess  Hospital  from  the 
Royal  Victoria  Hospital  in  Montreal,  which  my  patients  often  use 
to  advantage. 


FIG.  11. — Diabetic  crockery.  The  ramekin  level  full  with  Quaker  Oats  holds  30 
grams.  When  packed  tightly  with  5  per  cent,  vegetables  or  potato,  it  holds  90 
grams,  but  when  filled  in  the  ordinary  manner  holds  75  grams.  (Ramekin  and 
pitcher  for  sale  by  Jones,  McDuffee  and  Stratton  Co.,  Boston,  Mass.) 

In  order  to  illustrate  the  errors  which  easily  arise  from  general 
statements  about  foods,  the  accompanying  illustration,  Fig.  12,  is 
inserted. 

B.    THE  DIET  OF  DIABETIC  INDIVIDUALS. 

1 .  Caloric  Needs  of  the  Diabetic. — The  diet  of  the  diabetic  patient 
should  contain,  except  for  brief  intervals,  the  minimum  number  of 
calories  which  the  normal  individual  would  require  under  similar 
conditions.  1  am  convinced  that  many  normal  individuals  must 
live  upon  less  than  30  calories  per  kilo,  and  repeatedly  one  sees 
diabetic  patients  over  fifty  years  of  age  who  live  upon  less  for  long 
periods  of  time.  Thus  Case  No.  1094,  aged  fifty-seven  years,  whose 
diabetes  began  at  fifty-five,  showed  a  glycosuria  of  7.2  per  cent,  on 
July  2(>,  but  became  sugar-free  in  three  days  by  gradual  restriction 
of  carbohydrate  to  20  grains  and  protein  to  10  grams.  During  the 
following  fourteen  days  she  received  an  average  of  718  calories  each 
twenty-four  hours  and  her  weight  fell  from  71  kilos  to  70  kilos 
(157f  to  155  pounds).  During  the  following  nineteen  days  it 
remained  unchanged  (156  pounds)  and  the  calories  per  day  averaged 
1837. 


252 


DIET  IX  HEALTH  AND   7AT   DIABETES 


FIG.   12. — Variations  in  the  sizes  of  common  foods.1 

Three  E<J<jx.            Crams.  Grams.  t'.ram 

\Voijzht  of  one  o^^ 70  00  .r>0 

Protein  in  one  ejztc 7  (>  5 

Fat  in  one  e^« 7  0  5 

Three  Point  <>/'.•<. 

Weight  of  one  potato 120  00  00 

Carbohydrate  in  potato 21  IS  12 

Three  Ornn/jiK. 

"Weight  of  one  orange lii~>0  225  I.IO 

Carbohydrate  in  ouo  oningc 20  !.">  10 

Thnc  (!rti]>t'fruit. 

Weight  of  one  grapefruit 900  GOO  300 

Carbohydrate  in  one  grapefruit       ....     40  30  20 

1  See  footnote,  p.  2.r>3. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  253 

Case  No.  1100,  with  onset  of  diabetes  at  the  age  of  sixty,  came  to 
me  eight  months  later.  She  was  sugar-free  and  evidently  living 
upon  a  moderate  diet.  During  twelve  days  at  the  hospital  her 
weight  was  constant  at  58  kilos  and  the  calories  per  day  averaged 
1400.  Like  other  patients  of  similar  age,  she  felt  overfed. 

If  the  physician  allows  his  patient  to  go  untreated  and  excrete 
sugar  and  /3-oxybutyric  acid  in  the  urine  instead  of  burning  these 
in  the  body,  he  must  add  for  each  gram  of  sugar  so  lost  4  calories 
(actually  4.1)  and  for  each  gram  of  /3-oxybutyric  acid  5  calories 

TABLE  121. — ESTIMATED  DIET  OF  CASE  No.  1147  PRIOR  TO  TREATMENT. 

Carbohydrate,  Protein,  Fat, 

Food  grams.  grains.  grams.  grams. 

Eggs,  12 0  72  72 

5  per  o^nt.  vegetables,  450    ...  15  8  0 

Milk,  2000 96  64  64 

40  per  cent .  cream,  240  ....  8  8  96 

Butter,  90 0  0  75 

Meat,  120 0  32  20 

Bread,  100 60  10  0 

Totals  .  .      .    179  194  327 

449 


Total  calories 716  776  2943 

Total  calories  4435  -4-  72  (kilograms)  =  approximately  60  calories  per  kilogram 

body  weight. 

(actually  4.693).  I  use  the  figure  5  calories  for  1  gram  /3-oxy- 
butyric acid  because,  along  with  this  acid,  a  certain  amount  of 
acetone  and  diacetic  acid  also  escape  so  that  the  allowance  of  5 
calories  for  all  three  is  undoubtedly  too  low  rather  than  too 
high.  Case  No.  344,  page  148,  shows  the  importance  of  the  loss 
of  acid  bodies  as  well  as  of  sugar.  (See  Table  177.)  And  this  is 


Fig.  12  shows: 

1.  How  readily  errors  may  occur  in  estimating  the  food  values  of  the  diet  unless 
definite  quantities  of  foodstuffs  are  prescribed. 

2.  The  absurdity  of  reckoning  food  values  to  the  fraction  of  a  gram  unless  actual 
analyses  of  each  food  as  served  are  made. 

Errors  in  eggs  may  compensate  themselves,  because  the  eggs  average  about  60 
grams  (and  must  so  average  in  some  communities) ;  errors  in  potatoes,  oranges  and 
grapefruit  must  necessarily  be  very  great.  The  largest  of  the  three  potatoes  is 
actually  a  small  potato;  the  potato  weighing  GO  grams  is  about  the  size  of  an  egg; 
the  oranges  from  left  to  right  are  sold  under  the  trade  names  of  126,  170  and  250 
(to  the  box)  and  the  grapefruit  under  the  trade  names  of  28,  64  and  96  (to  the  box). 

It  is  partly  on  account  of  the  ease  with  which  large  errors  in  the  carbohydrate 
content  of  food  may  occur  that  it  is  desirable  to  give  to  patients  with  a  low  carbo- 
hydrate tolerance  their  carbohydrate  in  the  form  of  5  per  cent,  vegetables  exclusively, 
for  an  error  in  weighing,  reaching  120  grams  (4  ounces),  would  amount  to  but  a  few 
grams  of  carbohydrate. 

The  weights  and  food  values  given  for  the  various  foods  in  the  illustration  are 
not  absolutely  but  they  are  approximately  correct. 


254  DIET  IN  HEALTH  AND  IN  DIABETES 

not  all,  for  when  acidosis  is  extreme,  Benedict  and  I  have  shown  that 
the  metabolism  is  increased  about  15  per  cent.,  and  consequently 
more  calories  are  required  to  meet  this  demand.  It  is  seldom  one  can 
obtain  definite  knowledge  of  a  patient's  diet  before  treatment  is 
begun,  but  with  Case  No.  1 147  the  figures  appeared  reliable,  though 
they  show  an  attempt  to  lower  the  carbohydrate  in  the  food.  A 
lady,  aged  thirty-five  years,  with  diabetes  of  two  and  a  half  years' 
duration,  lost  in  a  little  more  than  this  interval  00  pounds.  On 
October  0,  1910,  the  volume  of  urine  was  estimated  at  0000  c.c.,  and 
the  sugar  was  found  to  be  5  per  cent,  or  300  grams — the  equivalent 
of  a  loss  of  1200  calories  in  twenty-four  hours.  She  reported  her 
daily  diet  to  have  been  as  shown  in  Table  121,  on  page  253. 

After  a  two  weeks'  stay  in  the  hospital  she  felt  more  content 
with  a  diet  of  1 000  calories  than  when  upon  that  at  entrance,  and  her 
weight  was  constant  during  the  last  four  days.1  It  is  obvious  that 
the  saving  of  food  hereby  entailed  would  be  considerable.  It  is  the 
diet  of  the  untreated  diabetic  which  is  expensive. 

2.  Carbohydrate. — The  total  carbohydrate  in  the  diet  of  diabetic 
patients  is  almost  invariably  restricted,  and  seldom  exceeds  100 
grains.  This  is  a  decrease  to  approximately  25  per  cent,  of  the 
normal  carlx)hydrate  ration,  and  so  radically  changes  the  composi- 
tion of  the  normal  diet  as  to  make  it  self-evident  that  rapid  changes 
from  a  normal  to  a  diabetic  diet  containing  even  100  grams  carbo- 
hydrate might  easily  cause  indigestion  in  normal  as  well  as  in 
diabetic  individuals. 

The  character  of  the  carbohydrate  has  comparatively  little  effect 
upon  its  assimilability.  Various  methods  have  been  employed  to 
test  the  assimilation  of  the  different  carbohydrates  and  the  evidence 
is  presented  in  the  following  paragraphs. 

(a)  The  Assimilability  of  Starch  and  the  Various  Sugars. — The  assimil- 
ability of  sugar  can  be  tested  by  the  oral,  subcutaneous,  and  intravenous 
methods  of  administration,  and  Allen2  has  pointed  out  in  detail  the  striking 
differences  which  result.  The  oral  method  is  convenient,  but  inaccurate 
on  account  of  variation  in  the  rate  of  absorption.  The  intravenous  method 
merely  gives  the  saturation  limit  of  the  blood  and  tissues  for  sugar  which 
can  take  place  without  the  sugar  overflowing  the  kidneys,  and  hence  is 
affected  by  slight  variations  in  renal  permeability.  The  subcutaneous  test 
is  the  best  test  of  all  of  the  power  of  the  body  to  utilize  sugar.  By  it 
errors  in  absorption  are  minimized  and  the  liver  avoided,  and  the  actual 
efficiency  of  the  tissues  in  storing  or  burning  the  sugar  is  determined. 

The  relations  of  the  tests  are  brought  out  interestingly  by  the  case  of 
levulose.  ''The  oral  tolerance;  of  levulose  is  not  much  less  than  that  of 
dextrose,  because  the  liver  stops  nearly  all  the  levulose.  The  intravenous 
tolerance  of  levulose  is  approximately  the  same  as  that  of  dextrose,  for  the. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  255 


value  represents  a  more  immediate  saturation  limit.  The  subcutaneous 
tolerance  of  levulose  is  a  very  small  fraction  of  that  of  dextrose,  because 
this  method  tests  the  power  of  the  general  tissue  to  utilize  levulose,  and 
this  power  is  easily  exceeded."  In  other  words,  the  intravenous  method 
shows  the  saturation  limit,  the  oral  method  furnishes  a  test  for  the  hepatic 
function,  and  the  subcutaneous  method  shows  the  utilization  by  the  tissues, 

Blumenthal  found  that  the  amount  of  sugar  injected  into  a  rabbit  to 
cause  glycosuria  varied  between  1.8  and  2.8  grams  per  rabbit  (about  0.8 
grams  per  kilo)  in  injections  lasting  from  one  to  two  minutes,  and  ho 
records  that  the  saturation  limits  of  dextrose  and  levulose  are  almost  equal. 
For  galactose  it  is  much  less;  for  saccharose  and  lactose  it  is  very  small. 
Comessatti  found  the  tolerance  to  be  between  2  and  2.5  grams  of  dextrose; 
by  having  the  rabbits  run  in  a  treadmill  the  tolerance  was  raised  about  20 
per  cent.  Kausch,  with  Bcrendes,  has  recommended  the  use  of  intra- 
venous injections  of  dextrose  for  their  stimulating  and  nutritive  value. 
The  solutions  used  were  from  2  to  10  per  cent.  They  gave  intravenous 
injections  of  1  or  2  liters,  slowly  and  without  ill  effect,  and  glycosuria  was 
absent  or  insignificant.  One  woman  with  puerperal  sepsis  and  temperature 
above  10(i°  received  up  to  2900  c.c.  daily,  with  excretion  varying  only  from 
0.2  gram  to  3  grams. 

The  rate  of  injection  is  an  important  factor.  Allen,1  from  whom  I 
have  abstracted  most  of  these  data,  says:  "The  rate  of  utilization  is  the 
essential  thing  to  be  tested;  not  the  quantity  of  sugar  which  may  perhaps 
circulate  and  recirculate  in  the  blood  without  overflowing  the  kidney,  but 
the  speed  with  which  the  tissues  can  withdraw  the  sugar  from  the  blood." 
Allen  believed,  writing  prior  to  Woodyatt,  Sansum,  and  Wilder,  that  the 
intravenous  method  may  yield  results  interesting  for  comparison  with 
those  of  other  methods,  but  considering  that  its  apparent  exactness  is 
probably  fallacious,  it  cannot  be  accepted  without  further  demonstration 
as  a  test  of  the  power  of  the  tissues  to  utilize  sugar. 

The  whole  subject  of  the  assimilation  of  carbohydrates  by  the  oral, 
intravenous  and  subcutaneous  methods  was  exhaustively  discussed  by 
Allen  in  1913,  and  I  abstract  freely  from  his  writings. 

The  assimilability  of  starch  is  practically  without  limit  in  health,  though 
glycosuria  may  occur  after  its  administration  to  febrile  and  alcoholic 
patients.  It  is  doubtful  if  there  is  any  difference  in  the  assimilability  of 
various  forms  of  starch.  The  question  will  be  discussed  more  fully  under 
oatmeal  and  potato  cures  in  diabetes.  The  apparently  better  assimi- 
lability of  one  form  of  starch  over  another  is  very  likely  to  be  explained 
by  variation  in  the  rate  of  absorption. 

The  assimilability  of  various  sugars  in  health  has  been  carefully  studied 
but  with  quite  divergent  results.  This  is  not  surprising  because  little 
account  has  been  taken  of  the  capacity  of  the  body  to  store  sugar. 

Woodyatt,  Sansum  and  Wilder2  recently  have  urged  the  importance 
of  time  in  determining  sugar  tolerance.  Tolerance  must  be  measured  and 
expressed  in  grams  of  glucose  or  other  sugar  per  kilogram  of  body  weight 
per  hour  of  time.  They  point  out  that  sugars  administered  by  the  stomach 
take  varying  lengths  of  time  to  be  absorbed,  according  to  the  motor  power 
of  the  stomach  or  intestines,  and  even  if  sugars  are  given  subcutaneously 
or  by  any  other  route,  which  demands  absorption  as  a  prelude  to  their 
entering  the  blood,  the  rates  at  which  they  enter  the  blood  will  depend 
ui)on  the  rates  at  which  they  are  absorbed.  They  have  devised  a  method 

1  Allen:  Loc.  cit.,  p.  54, 

2  Woodyatt,  Sansum  and  Wilder:  Jour.  Am.  Med.  Assn.,  1915,  Ixv,  p,  2067. 


256  DIET  IN  HEALTH  AND  IN  DIABETES 

by  which  solutions  of  the  various  sugars  can  be  easily  and  painlessly  injected 
into  animals  or  man  for  hours  at  a  time.  By  the  use  of  these  methods, 
they  found  that  a  man  can  utilize  O.S5  gram  of  glucose  per  kilogram  of 
body  weight  per  hour  for  from  six  to  twelve  hours  without  producing  any 
glycosuria,  or  even  diuresis.  In  other  words,  a  man  weighing  70  kilograms 
when  resting  quietly  in  bed  may  and  did  receive  and  utilize  GO  grams  of 
glucose  by  vein  per  hour  without  glycosuria.  This  would  amount  to  252 
calories  per  hour.  This  apparently  is  the  normal  tolerance  limit  for 
glucose.  In  cases  of  exophthalmic  goitre,  the  intravenous  tolerance  was 
found  to  be  as  low  as  0.(>5  gram  per  kilogram  per  hour.  For  lactose  it  was 
nearly  zero.  If  twice  the  normal  tolerance  limit  for  glucose — that  is,  1.7 
grams  per  kilogram  per  hour — are  given,  0.17  gram  glucose  per  kilogram  per 
hour  are  excreted  by  the  urine,  but  if  glucose  is  given  at  a  rate  faster  than 
2  grains  per  kilogram  per  hour,  50  per  cent,  of  all  the  glucose  injected  appears 
in  the  urine  when  constant  conditions  have  been  secured. 

In  a  normal  individual,  the  greatest  rate  of  glycosuria  which  can  be 
produced  by  feeding  any  quantity  of  glucose  by  mouth  is  limited,  and  at 
most  approximates  that  which  is  produced  by  an  intravenous  injection 
at  the  rate  of  1.8  grams  per  kilogram  per  hour.  Hence  it  would  be  reason- 
able to  believe  that  when  sugar  is  given  by  mouth  in  health,  it  is  never 
absorbed  faster  than  at  this  rate. 

The  above  investigators  also  found  that  when  glucose  was  given  at 
rates  exceeding  O.So  gram  per  kilogram  per  hour  and  the  glucose  begins  to 
accumulate  in  the  tissues  and  pass  out  into  the  urine,  it  carries  water  with  it. 
When  the  sugar  is  given  at  the  rate  of  5.4  grams  per  kilogram  per  hour, 
marked  diuresis  results — thus,  in  a  dog  the  urine  output  rises  rapidly  to  the 
vicinity  of  350  c.c.  per  hour.  If  each  hour  the  dog  received  enough  water 
to  make  good  the  loss,  this  rate  of  diuresis  or  a  higher  one  could  be  main- 
tained for  long  periods  of  time.  If  enough  water  is  not  given  to  counter- 
balance the  urinary  loss,  the  volume  of  urine  decreases  and  the  dog  suffers 
from  thirst  and  death  may  ensue.  On  the  other  hand,  if  too  much  water  is 
given  with  the  hourly  injections  of  glucose  of  5.4  grams  per  kilogram  per 
hour,  there  is  danger  of  stopping  the  heart  mechanically.  In  giving  intra- 
venous injections  of  glucose  there  arc  then  two  things  to  avoid:  too  great 
dehydration  on  the  one  hand,  and  heart  failure  from  imposing  too  much 
mechanical  work  on  the  other.  These  can  both  be  avoided  by  knowing 
the  number  of  grams  of  glucose  which  enter  the  body  hourly,  and  what 
volume  of  water  is  removed  by  such  a  rate  of  sugar  injection. 

TABLE   122. — THE  RELATIVE  ASSIMILABILITY  OF  VARIOUS  SUGARS  AS 
DETERMINED  BY  THE  APPEARANCE  OF  SUGAR  IN  THE  URINE. 

Intravenous  method, 
Oral  administration.    Wootlyatt,  Sansum  and  Wilder. 

Total  in  Per  kilo,  per  hour, 

Von  Noorden.  grains.  grains. 

Dextrose 150- ISO  O.So 

Lovulose 120-150  0.15 

Galartose 20-15'  0.10 

Lactose 120+                                0  approximately 

(1)  Ulncosc. — The  tolerance  for  glucose  is  apparently  unaffected  by  season 
or  sex,  and  there  is  no  constant  difference  for  different  races.  Il  is  interest- 
ing that  children  are  supposed  to  have  a  far  higher  tolerance1  than  adults, 

1  Hoffmann:  Ztschr.  f.  Kxp.  Path.  u.  Therap.,  101-1,  xvi,  p.  :WS;  cit.  Jour.  Am.  Med. 
Assn.,  1015,  Ixiv,  p.  253. 


THE   DIET  OF   DIABETIC  INDIVIDUALS  257 

but  Allen's  experiments  with  young  animals  were  to  the  contrary.  The 
increased  tolerance  in  children  might  be  explained  by  their  increased 
activity.  In  general,  the  tolerance  for  glucose,  like  that  of  other  carbohy- 
drates, varies  inversely  with  the  rapidity  of  its  absorption.  Its  assimilation 
is  increased  in  fever.  The  occasional  appearance  of  glycosuria  in  fever  is 
considered  by  Allen  not  to  invalidate  this  statement,  because  that  is  a  toxic 
glycosuria.  Actual  increased  temperature  favors  tolerance,  possibly  by 
rendering  the  kidneys  less  permeable,  but  chiefly  by  increasing  utilization 
in  the  tissues.  The  influence  of  muscular  work  in  increasing  the  tolerance 
for  dextrose  has  been  proven  by  experiments  upon  animals  and  is  analogous 
to  the  effect  of  work  upon  the  assimilation  of  carbohydrates  in  general. 
Glycosuria  may  be  produced  experimentally  by  intravenous,  subcutaneous, 
oral  and  intraperitoneal  administration  of  sugar.  It  is  not  produced  by 
rectal  injections,  this  being  the  one  method  by  which  glycosuria  is  impos- 
sible under  normal  conditions. 

Various  methods  have  been  employed  to  test  the  presence  of  diabetes 
by  the  administration  of  glucose,  and  Bergell  describes  a  method  by  which 
a  predisposition  to  diabetes  can  be  detected.  (See  p.  287.)  With  this  I  have 
no  experience.  Xaunyn's1  method  is  as  follows :  The  patient  has  a  breakfast 
of  80  to  100  grams  of  bread  and  a  cup  of  coffee  with  milk.  Two  hours  later 
he  is  given  100  grams  dextrose.  If  glycosuria  occurs  to  a  degree  which 
can  be  determined  quantitatively,  the  diminished  power  of  assimilation  for 
dextrose  is  demonstrated.  Mere  traces  in  the  urine  are  disregarded. 
Alimentary  glycosuria  of  this  type  generally  begins,  according  to  von 
Noorden,2  within  three-quarters  to  one  hour  after  a  large  dose  of  sugar,  and 
lasts  three  hours.  The  total  excretion  is  not  under  2  per  cent.,  and  not 
over  5  per  cent,  of  the  sugar  ingested.  In  Bright's  disease  the  test  may 
be  obscured,  and  in  diabetes,  complicated  by  Bright's  disease,  the  effect 
may  not  show  itself.  Table  123  compiled  by  Allen  from  the  experiments 
of  Tachau  is  interesting.  Tachau  tested  the  blood-sugar  fasting,  and  one 
hour  after  100  grams  dextrose  were  given  by  mouth. 

TABLE  123. — CHANGES  IN  BLOOD  SUGAR  AFTER  ADMINISTRATION  OF  100 
GRAMS  OF  DEXTROSE. 3 

Blood  sugar. 

After  100  Kin. 

Fasting,  dextrose,  Glycosuria, 

Condition.  per  cent.  per  cent.  per  cent. 

Normal O.OS5-O.OS6  0.060-0.070  0 

Diabetes        0.110-0.169  0.207-0.225  0.3-0.4 

Lead    poisoning    (with    glyco- 
suria)      0.097                      0.149  0.1 

Four  other  cases  of  lead  poison- 
ins        0.105  0. 121-0. 256  Neg.  in  3  out  of  4 

Various  fevers O.OS5-0. 110  0.125-0.200  0 

Chronic  nephritis     ....  0.091-0.104  0.111-0.216  0 

Higgins1  has  studied  the  time  at  which  the  various  sugars  begin  to  be 
burned  in  the  body  by  the  change  in  the  gaseous  exchange  and  especially 
in  the  respiratory  quotient.  He  found  that  glucose  and  maltose  were  not 
utilized  as  food  as  soon  as  the  other  sugars — sucrose,  lactose  and  levulose — 
for  the  former  begin  to  be  burned  in  twenty  to  thirty  minutes,  but  the  latter 

1  Xaunyn:  Loc.  cit.,  p.  37.  -  Von  Noorden:  Loc.  cit.,  p.  21. 

3  Cited  from  Allen.     See  Tachau:  Deut.  Arch.  f.  klin.  Med..  1911,  civ,  p.  437. 

4  Higgins:  Jour.  Phys.,  1916,  xli,  p.  25.S. 

17 


258  DIET  IX  HEALTH  AXD  IX  DIABETES 

\vithin   ton  minutes.     He  further  observed  a  distinct   difference  in  men 
between  the  metabolism  of  glucose  and  of  levulose  and  g'alactose. 

\Ve  often  erroneously  think  of  an  excess  of  sugar  in  the  blood  as  being 
removed  by  the  kidneys.  As  a  matter  of  fact,  this  is  not  the  case,  for 
the  kidneys  remove  only  a  trifle  of  the  excess  of  the  sugar.  They  by 
no  means  regulate  the  percentage  of  sugar  in  the  blood.  By  far  the,  greater 
portion  of  the  sugar  is  removed  from  the  blood  by  the  tissues,  as  Meltzer 
and  Kleiner1  have  so  beautifully  demonstrated,  and  recently  Woodyatt, 
Sansum  and  Wilder  have  confirmed. 

(2)  Saccharose. — Le  ( loff-  found  that  saecharosuria  and  glycosuria  resulted 
in  100  per  cent,  of  the  cases  after  100  grams  cane-sugar  \vere  administered 
orally.  Saccharose  has  lit  tie  place  in  the  diet  of  primitive  races,  and  Allen  has 
pointed  out  a  possible  connection  between  the  increased  use  of  saccharose 
and  the  increased  incidence  of  diabetes.  (See  p.  o().)  Tntil  the  increased 
incidence  of  diabetes  is  thoroughly  proven,  one  must  be  slow  to  consider 
this  relation  established. 

(.'->)  Lactose. — The  poor  assimilation  of  lactose  is  remarkable  because  it 
is  the  one  distinctively  normal  sugar.  This  lack  of  assimilation  holds  in 
diabetes  as  well  as  in  health.  It  is  perhaps  due  to  the  fact  that  lactose 
is  broken  up  into  galactose  and  dextrose  before  it  is  absorbed.  (The 
question  will  be  further  discussed  under  the  so-called  Milk  Cure,  page  377.) 
It  should  be  pointed  out  here  that  milk  contains  f>  per  cent,  lactose,  whereas 
there  is  in  cream  little  more  than  2.5  to  3  per  cent.  Buttermilk  and 
skimmed  milk  contain  essentially  the  same  percentage  of  sugar  as  pure 
milk,  but  with  the  fat  removed  the  milk  is  far  less  nourishing  and  thus  if 
given  exclusively  it  represents  a  type,  of  low  calorie  diet.  Fermented 
milks  may  contain  ,'i  per  cent,  sugar. 

(4)  M(dtoxc. — It  is  commonly  agreed  that  maltose  is  tolerated  less  well  by 
diabetics  than  any  other  form  of  sugar. 

(o)  Lcruluxc. — The  advertisement  of  levulose  by  a  leading  drug  firm  as 
completely  assimilable  in  both  mild  and  grave  forms  of  diabetes  would 
be  amusing  were  it  not  that  occasionally  one  sees  doctors  and  patients 
who  believe  the  statement  to  be  true. 

The  behavior  of  levulose  in  depancreatized  dogs  is  quite  different  from 
that  of  glucose.  For  example,  .such  dogs  can  form  glycogen  from  levulose 
when  they  cannot  form  it  from  dextrose.  This  is  worthy  of  consideration 
because;  of  the  possibility  of  this  fact  being  utilized  in  some  way  in  treat- 
ment. For  a  long  time  one  of  the  first  additions  which  I  have  made  to  the 
diabetic  diet  after  green  vegetables,  has  been  an  orange*  or  grapefruit.. 
During  the  last  two  years  Benedict  and  I  have  made1  many  tests  with  lovu- 
lose  iiiion  diabetie-  patients.  These  will  probably  be  published  during  this 
year.  (See1  p.  .'->7>. ) 

Strauss'  introduced  le-vulose  as  a  test  of  hepatic  function.  Whereas 
normal  individuals  and  patients  with  supposedly  normal  live'rs  assimilate 
100  grams  levulose  completely,  approximately  SO  per  cent,  of  patients 
with  hepatic  disorders  show  levulosuria.  In  the  last  few  years  this  test,  as 
we'll  as  others  of  a  similar  nature,  has  lost  rather  1  han  gained  in  reputation, 
as  pointed  out-  by  Friedman1  and  Strauss. 

(('))  (riiluclo.^'.  All  agree  that  galactose  is  poorly  assimilated,  and  yet  it 
is  fermented  with  more  difficulty  than  eitlieT  de'xtrost;  or  levulexse. 

'Seep.  HI- 

2  ('it.  by  Allen:    Coin  pi.  rend,  clc  1'Acad.  tics  so.,  1011,  clii,  p.  17S5. 
3S'r:iuss:    Di'iitsrli.  incd.  \VcliiiM-hr.,   I'.Mll,  xxvii,  p.  7~>7. 
4l-'riedmu!i  and  Struu~r-:    Arch.  Int.  Mod.,   I'.M  I.  xiv.  p.  f>.'U . 


THE  DIET  OF  DIABETIC  INDIVIDUALS  259 

(7)  Inulin. — Inulin  is  a  polysaccharid  of  Icvulosc  and  in  this  respect 
comparable  with  starch,  which  is  a  polysaccharid  of  dextrose.  It  occurs 
in  the  roots  of  many  composites  such  as  the  tubers  of  dahlia  and  artichoke. 
No  enzymes  in  the  alimentary  tract  are  known  to  convert  it  into  sugar, 
but  the  normal  acidity  of  the  gastric  juice  may  effect  a  partial  hydrolysis 
of  inulin  to  levulose.  The  bulk  of  the  inulin  is  decomposed  in  the  gastro- 
intestinal tract  into  non-carbohydrate  products.'  Following  the  feeding  of 
inulin  to  phlorizinized  animals  Lewis  and  Franker2  found  no  increase  in 
glycosuria  which  one  would  expect  if  any  of  the  inulin  had  been  converted 
to  levuloftC.  Consequently  there  appears  to  be  no  reason  for  the  employ- 
ment of  inulin  in  the  diabetic  diet  except  to  afford  bulk. 

Mary  Schwartz3  found  no  evidence  that  the  carbohydrates  of  lichens, 
alga1,  and  related  substances  were  assimilated  by  human  beings. 

(b)  The  Estimation  of  the  Carbohydrate  in  the  Diabetic  Diet. — The 
quantity  of  carbohydrate  in  the  various  foods  is  easily  calculated 
and  far  more  simply  than  is  usually  thought.     This  is  not  true  if 
one  desires  scientific  accuracy,  for  in  that  event  analyses  of  the 
food  given  the  patient  must  be  made. 

(c)  Carbohydrate  in  Vegetables. — Loss  in  Cooking. — It  would  appear 
perplexing  to  determine  the  amount  of  carbohydrate  in  the  various 
vegetables  which  the  patient  eats  in  twenty-four  hours,  but  this  is 
really  not  the  case.    For  convenience  I  have  classified  the  vegetables 
and  fruits  which  enter  into  the  diabetic  diet  under  four  headings — 
those  containing  approximately  5  per  cent.,  10  per  cent.,  1")  per  cent., 
and  20  per  cent,  carbohydrate.     (See  Table  124.) 

It  is  true  that  there  is  considerable  variation  in  each  group, 
but  the  average  content  is  not  far  from  that  represented,  the  error 
being  on  the  lower  side.  This  does  not  hold  for  string  beans,  for 
often  trouble  occurs  from  the  beans  having  developed  into  maturity, 
thus  greatly  increasing  their  content  in  carbohydrate.  Many  an 
unexplained  trace  of  sugar  in  the  urine  has  undoubtedly  occurred 
in  this  way. 

A  deduction  should  be  made  in  the  percentage  of  carbohydrate 
in  the  vegetables  of  the  5  and  10  per  cent,  groups  because  a  part 
of  the  carbohydrate  is  in  the  form  of  cellulose,  and  this  is  not 
assimilable.  For  this  reason  3  per  cent,  and  (i  per  cent,  represent 
more  accurately  the  content  of  available  carbohydrate  in  the  5 
per  cent,  and  10  per  cent,  vegetables.  This  being  the  case,  it  is 
convenient  and  fairly  accurate  to  consider  30  grams,  or  1  ounce  of 
5  per  cent,  vegetables,  to  contain  1  gram  carbohydrate  and  the  same 

'Editorial:  Jour.  Am.  Mod.  Assn.,  1914,  Ixiii,  p.  326. 

2  Lewis  and  Frankel:  Jour.  Biol.  Chem.,  1014,  xvii,  p.  305. 

3  Schwartz:  Tr.  Conn.  Acad.,  Art  and  Sciences,  1911,  xvi,  p.  247. 


260 


DIET  IN  HEALTH  AND  IN  DIABETES 


quantity  of  10  per  cent,  vegetables  2  grams  of  carbohydrate.  The 
vegetables  in  the  15  per  cent,  and  20  per  cent,  groups  should  be 
reckoned  at  their  full  value. 

TAIU.K   124. — FOODS  AHKANCKD   AITKOXI.MATKI.V  A<VOHI>I\<;  TO   I'KKCKNTACE 

OF  (  'AKHOIIYDKATKS. 


VECJ 

ETABLES* 

(Fres 

h  or  canned) 

per  cent. 

10  per  cent. 

!.">  J>:T  cent.                   2'')  per  cent. 

Lettuce 

Tomatoes 

Pumpkin 

(  Ireen  jjeas                 Potatoes 

(  'ucumbers 

Brussels 

Turnip 

Artichokes 

^helled  beans 

Spinach 

sprouts 

Kohl-rabi 

(Jerusalem) 

Baked  beans 

Asparagus 

Water  cress 

Squash 

Parsnips 

Green  corn 

Rhubarb 

Sea  kale 

Beets 

(  'aimed  lima 

Boiled  rice 

Endive 

Okra 

Carrots 

beans 

Boiled 

Marrow 

Cauliflower 

Onions 

macaroni 

Sorrel 

Kgg  plant 

Mushrooms 

Sauerkraut 

Cabbage 

Beet  greens 

Radishes 

I  )andelions 

Leeks 

Swiss  chard 

String  beans 

(  Vlery 

Broccoli 

I 

'HUITS 

Ripe  olives 

(•20  ]>er  cent,   fat) 

Oranges                      Apples 

Plums 

(  irapefruit 

Cranberries 

Pears 

Bananas 

Lemons 

Strawberries 

Apricots 

Prunes 

Blackberries 

Blueberries 

Gooseberries 

Cherries 

Peaches 

Currants 

Pineapple 

Raspberries 

Watermelon           '  Huckleberries 

Butternuts 

NUTS 

Brazil  nuts 

Almonds                      Peanuts 

Pignolias 

Black  walnuts 

Walnuts 

Hickory 

(English) 

Pecans 

Beechnuts                       -I"  ]><T  cent. 

Filberts 

Pistachios                   Chestnuts 

Pine  nuts 

MISCI 

ILLANEOUS 

.        *Reckon    available    carbohydrates    in    vegetables 

Unsweetenei 

an<1      '"^'"•("1    ,,f  .-,  por  ,,,„,.  Krmip  as  :',  per  cent.,  of   10  per  rent. 

pickles,  cl 

tins,  ovstcrs.   seal-                      ,. 

group  as  (.  per  cei  t. 

lops,  liver 

fish  roe. 

Manx'  of  the  vegetables  under  the  5  per  cent,  group  contain 
very  little  carbohydrate;  for  instance,  lettuce  contains  2.9  per  cent., 
spinach  li.2  per  cent.  In  general  the  vegetables  are  arranged  in  each 
group  in  sequence  according  to  their  content  of  carbohydrate. 

Indeed,  one  will  not  be  very  wrong  if  he  considers  the  total  carbo- 
hydrate of  the  5  per  cent,  vegetables  which  a  diabetic  patient  will 
eat  as  10  to  20  grams  in  the  twenty-four  hours.  As  an  actual  fact, 


THE  DIET  OF   DIABETIC  INDIVIDUALS  261 

300  grams  of  a  mixture  of  5  and  10  per  cent,  vegetables  served 
to  a  diabetic  patient  at  the  New  England  Deaconess  Hospital  were 
found  by  analyses  at  the  Nutrition  Laboratory  to  contain  10  grams 
carbohydrate. 

Vegetables  lose  carbohydrate  in  the  cooking,  and  this  loss  is  favored 
first  by  changing  the  water  in  which  they  are  prepared  two  or  three 
times,  and  second,  by  preparing  the  vegetables  in  finely  divided 
form  so  that  the  water  can  have  easy  access  to  the  whole  mass. 
Von  Noorden1  pointed  out  that  100  grams  of  raw  spinach  contained 
2.97  grams  carbohydrate,  but  cooked  spinach  only  O.Sa  gram. 
Similarly,  100  grams  of  ripe  peaches  contained  9.~>  grains  carbohy- 
drate, but  when  boiled  and  the  water  changed,  only  l.S  grams. 
Allen2  has  utilized  this  method  of  removing  carbohydrate  from  vege- 
tables and  thus  allows  patients  to  have  bulk  in  their  diet.  He  terms 
vegetables  so  prepared  "thrice-cooked  vegetables."  "  Under  these 
conditions  the  vegetables  may  be  boiled  through  three  waters, 
throwing  away  all  the  water.  Nearly  all  starch  is  thus  removed. 
The  most  severe  cases  generally  take  these  thrice-cooked  vegetables 
gladly  and  without  glycosuria."  Patients  often  say  that  it  makes 
little  difference  to  them  whether  the  vegetables  are  thrice  washed  or 
not.  It  is  easy  and  useful  to  add  a  little  salt,  and  if  desired  the  vege- 
tables can  be  flavored  with  meat  juices  or  meat  extracts. 

Even  when  vegetables  are  cooked  in  the  ordinary  way  consider- 
able carbohydrate,  protein,  and,  what  is  quite  unfortunate,  salts  are 
lost.  Eew  analyses  of  cooked  vegetables  are  available,  but  some 
of  those  which  I  have  found  are  recorded  in  the  following  table: 

TABLE   125. — THE  INFLUENCE  OF  COOKINC;  UPON  THE  CONTENT  OF 
CARBOHYDRATE  IN  VEGETABLES. 

Carbohydrates. 

Fresh,  Cooked, 

Food.  per  cent.  per  cent. 

Asparagus 3.3  2.2 

Spinach 3.2  2.6 

Beans  (string) 7.4  1.6 

Beets ? 9.7  7.4 

Carrots 9.2  6.8 

Cabbage 5.0  3.7 

Greens  (beet) 3.2 

Onions 9.9  4.9 

Beets  (boiled)        10.0 

Parsnips 13 . 2 

Peas 16.9  14.6 

Potatoes IS.  4  20.9 

Potato  chips 46.7 

Sweet  potatoes .      .    27 . 4  42 . 1 

Through  the  kindness  of  Professor  Ruth  A.  Wardall,  of  the 
Department  of  Home  Economics  of  the  State  University  of  Iowa, 

1  Von  Xoorden:  Loc.  cit.,  p.  300. 

2  Allen:  Bost.  Mod.  and  Surg.  Jour.,  1915,  clxxii,  p.  241. 


2(Y2 


DIET   IX   HEALTH   A.\D   IX   DIABETES 


o  c 


THE   DIET  OF   DIABETIC  INDIVIDUALS  203 

working  in  Professor  Mendel's  laboratory  in  Yale  University,  I  am 
able  to  insert  Table  120,  which  shows  the  carbohydrate  in  washed 
vegetables. 

The  results  shown  in  this  table  are  simply  preliminary  experi- 
ments, but  they  are  of  so  much  value  that  they  deserve  attention. 
Professor  Wardall  finds  it  no  disadvantage  to  use  the  boiling 
temperature  for  each  of  the  extractions.  In  the  data  recorded  below, 
the  extractions  were  made  by  starting  the  vegetables  in  cold  water 
and  bringing  this  to  the  boiling-point  and  maintaining  it  at  this 
temperature  for  one  minute.  Hot  water  was  added  for  each  of  the 
other  extractions,  and  all  were  boiled  one  minute.  If  the  first  extrac- 
tion is  kept  at  150°  F.,  as  has  sometimes  been  recommended,  the 
second  extraction  leads  the  list  in  the  power  of  reduction  and  in 
fermentation,  the  first  extraction  ranking  after  the  third  or  fourth. 
In  general,  100  grams  of  the  fresh,  clean,  dry  vegetable,  weighed 
from  the  edible  portion,  were  used  for  each  analysis,  and  all  calcula- 
tions were  made  on  this  basis.  \Yith  the  exception  of  canned 
asparagus,  the  four  or  five  extractions  necessary  to  remove  all 
reducing  substances  left  the  vegetable  still  attractive  in  flavor  and 
appearance. 

For  practical  purposes  these  extractions  will  probably  be  found 
sufficient.  For  the  first,  place  the  vegetables  in  cold  water  and 
bring  the  same  to  the  boiling-point,  maintaining  the  tempera- 
ture for  three  to  five  minutes,  but  for  the  others  begin  with  hot 
water. 

It  is  only  right  to  Professor  Wardall  to  again  state  that  the 
figures  cited  in  the  above  table  represent  preliminary  analyses. 

(1)  Potatoes. — The  variation  in  the  percentage  of  carbohydrate  in 
potatoes  before  and  after  cooking  is  negligible,  save  with  potato 
chips,  in  which  it  more  than  doubles.  The  loss  of  protein  is  slight, 
but  if  soaked  in  cold  water  before  boiling  the  loss  of  protein  is  25 
per  cent,  and  of  mineral  matter  8X  per  cent.  If  the  potatoes  are  not 
soaked,  but  dropped  at  once  into  boiling  water  the  loss  is  much 
decreased  and  if  the  potatoes  are  boiled  with  the  skins  on  the  loss 
is  very  slight.  Emphasis  should  be  laid  upon  the  comparatively 
small  amount  of  carbohydrate  in  potato  in  comparison  with  its 
bulk  and  in  comparison  with  the  percentage  of  carbohydrate  in 
bread.  A  considerable  number  of  my  milder  cases  of  diabetes,  by 
giving  up  bread  and  bread  preparations  entirely,  have  been  able  to 
eat  potatoes  freely.  In  prescribing  potatoes  for  diabetic  patients 
it  is  desirable  to  designate  baked  potatoes,  for  these  can  be  eaten 
with  the  skins  if  pains  are  taken  to  have  them  carefully  cleaned  with 
a  scrubbing  brush  in  the  kitchen.  This  is  advantageous  in  two 
ways:  the  skins  are  quite  an  addition  to  the  meager  diet  of  the 
diabetic,  and,  furthermore,  they  counteract  constipation. 


2(14  DIET  IX  HEALTH  AND  IN  DIABETES 

(2)  Nuff}.—  Xuts  containing  15  and  20  per  cent,  carbohydrates  are 
probably  far  less  objectionable  than  most  other  foods  with  a  similar 
carbohydrate  content.     This  is  due  to  the  fact  that  in  such  nuts 
as  almonds  and  peanuts  a  larger  part  of  the  carbohydrate  is  in  the 
form  of  pentosan,  galactan,  or  other  hemicellnloses  which  probably 
do  not  readily  form  glucose.     I   do  not  know  how  much   of  these 
carbohydrates  is    utili/ed  by  the  individual.     This    would    furnish 
an  interesting  problem  for  investigation. 

(3)  Fruit. —  Fruit  is  most  desirable  for  a  diabetic  patient  if  his  tol- 
erance will  allow  him  to  take  it.     The  taste  is  agreeable,  it  serves 
instead  of  a  dessert,  and  so  relieves  the  patient  of  the  embarrass- 
ment of  sitting  idly  at  the  table  when  others  are  eating.     The  best 
varieties  of  fruit  for  diabetic  patients  are  grapefruit  (5  per  cent.), 
strawberries  (7.4  per  cent.),  and  oranges  (11. (>  per  cent.).     These 
fruits  are  safer  than  apples  (14.2  per  cent.)  for  the  patient,  because 
they  contain  5  to   10  per  cent,   less  carbohydrate  and  are  more' 
satisfying.     Furthermore,   it  is  less  easy  thoughtlessly  to  eat  an 
orange  than  an  apple  and  thus  break  dietetic  restrictions.     This 
practical  point  is  worthy  of  consideration  in  forbidding  apples. 
Von   Xoorden   also   records   unfavorable   results   from   the   use   of 
apples.     Unfortunately,  steaming  an  apple  removes  little  of  the 
carbohydrate  which  it  contains. 

TAHI.I;  127. — WEKIIITS  OF  (iK.u'KKitriT,  ORANCKS  AND  BANANAS  COMI-ARKD 
\VITH  EDIHLK   PORTIONS  AS  DKTKHMINICD   MY  A  XTRSE. 


Grapefruit. 
Whole.    Kinble  portion. 

VVhol. 

Orange. 
.    KdiWc  p. 

>rtion, 

Banana 
Whole.    K.lihlcp 

>rtion 

grains,      grains,         '/o 

grains 

Krams. 

.  0 

grams,      jjnims. 

'.[• 

Small     347           115          42 

Medium 

200 

118 

40 

149         92 

02 

Large     (Ml         320         47 

Law 

27") 

1  Hi 

42 

149          91 

61 

Florida                   .       .       . 

Small 
Medium 

2f>2 

2,>i 

113 

101 

4.") 

40 

1  2  1          74 
12o          79 

61 
63 

Large 

3os 

111 

40 

130          M 

02 

Small       . 

200 

108 

42 

119          74 

62 

California 

Medium 

27s 

121 

44 

100          91) 

00 

Largo      . 

2S2 

129 

4(1 

119        73 

01 

— 

14.")          S9 

61 

Yverage 

44 

107        101 

C>1 

15s          i)7 

61 

153          91 

61 

Average  111  S7  111 

C1)  Oranf/fft. — Tho  quantity  of  carbohydrate  in  a  small  orange  is 
not  far  from  10  grains.  My  children  counted  for  me  the  number  of 
compartments  in  forty-eight,  oranges,  and  found  these  to  vary 
between  nine  and  eleven  in  forty-three  instances,  but  in  three  there 
were  twelve  and  in  two  there  were  thirteen  compartments.  Con- 
sequently, one  \\ill  not  l>e  far  wrong  to  consider  that  one  compart- 
ment of  a  small  orange  contains  1  gram  carbohydrate.  The  same 


THE  DIET  OF  DIABETIC  INDIVIDUALS 


265 


statement  will  apply  to  one-half  of  a  small-sized  grapefruit.  It  is 
interesting  to  note  how  constantly  inconsistent  the  variations  are  in 
the  amount  of  edible  portions  in  small,  medium,  and  large  oranges 
as  prepared  for  patients  by  a  nurse.  Grapefruit  vary  more,  but  it  is 
not  difficult  to  select  one  of  moderate  size  or  to  take  less  of  a  large 
one.  Table  127  shows  these  variations.  Gross  appearance  and  the 
weight  of  the  edible  portion  do  not  correspond. 

The  observations  recorded  in  Table  127  prompted  me  to  pursue 
the  matter  further,  for  it  was  evident  that  inaccuracies  must  creep 
into  the  dietetic  calculations  in  this  way.  In  Tables  128  and  129 
are  shown  analyses  made  for  me  by  Edward  M.  Frankel,  Ph.D., 
on  aqueous  extracts  of  the  fruit  after  cautions  were  taken  to  remove 
the  bulk  of  the  protein  and  cellulose  with  lead  acetate.  The  results, 
therefore,  represent  the  amounts  of  water-soluble  carbohydrate 
calculated  as  glucose  after  hydrolysis.  No  account  is  taken  of  the 
insoluble  material  on  the  assumption  that  such  carbohydrate  not 
soluble  in  water  is  of  the  hemicellulose  type,  which  has  been  shown 
not  to  be  utilized  by  the  human  body.  I  am  especially  glad  to  have 
secured  Dr.  Frankel 's  analyses,  for  I  am  unaware  that  similar  facts 
have  been  recorded. 

Frankel  has  added  data  on  the  acidity  of  the  fruit  calculated 
as  citric  acid,  because  it  has  been  pointed  out  by  Greenwald1  that 
this  substance  is  converted  quantitatively  by  the  diabetic  organism 
into  glucose. 

TABLE  128. — ANALYSER  OF  ORANC.ES. 
Made  by  Edward  M.  Frankel,  Ph.D.,  New  Haven,  Conn. 


Sold  as 

Size. 

Gross 
weight, 
grams. 

Edible 
portion, 

grams.     % 

Grams  of 

sugar  as 
glucose. 

Percentage 
of  edible 
portion. 

Total 

acidity  as 
citric  acid, 
grains. 

Percentage 
of  edible 
portion. 

Florida 

Small 

188 

152     81 

12.0 

7.9 

1.5 

1.0 

" 

Small 

109 

143     85 

12.3 

8.6 

" 

Medium 

214 

172     80 

12.4 

7.2 

1.2 

0.7 

" 

Medium 

215 

179     83 

15.7 

8.8 

" 

Large 

290 

222     80 

19.6 

8.4 

1.3 

0.6 

" 

Large 

357 

282     79 

19.7 

7.0 

" 

Large 

310 

243     7S 

20.4 

8.4 

California 

Small 

189 

149     79 

10.9 

7.3 

Small 

178 

149     84 

10.9 

7.3 

Medium 

250 

188     75 

17.5 

9.3 

2.2 

1.2 

Medium 

230 

170     72 

16.2 

9.5 

1.0 

0.9 

Medium 

270 

203     75 

17.2 

8.5 

Medium 

204 

193     73 

15.4 

8.0 

Large 

287 

220     77 

16.5 

7.5 

1.4 

0.6 

Large 

322 

219     68 

19.3 

8.8 

1.3 

0.6 

1  Greenwald:  Jour.  Biol.  Chem.,  1914,  xvii,  p.  115. 


2(10  DIET  IX  HEALTH  AXD  7.V   DIABETES 

TABI.K   129. — AXAI.YSKS  OF  GRAPEFRUIT. 
Made  by  Kdwanl  M.  Frankel,  Ph.D.,  Now  Haven,  Conn. 


Sold  as 

Size. 

Gross 
weight. 
grains. 

Kdiblo 
portion, 

grums.     r; 

drums  of     Percentage        .   °     '         Percentage 
sugar  as       c,f  edible       '"'laity  jis       ()f  ,,(lil)],. 
glucose,        portion.       curie  acid.       portion. 
grams. 

Portn  Kirn    Small 

401 

301      75 

24 

0              S.O                2.1                O.S 

Small 

42S 

31  S     74 

20 

7             S.4               2.3               0.7 

California 

Medium 

581 

419      77 

31 

7.1                0.5                1.4 

Medium 

550 

3!)4      72 

23 

S             0.0               0.4                1.0 

Larjie 

070 

515      70 

34 

s            O.s              5.0              1.1 

" 

Large 

77:i 

000     7s 

40 

.0            7.7              0.7               1.1 

Florida 

Small 

53S 

40!)      70 

25 

.0             0.1                1.2                1.0 

" 

Medium 

712 

53!)      7(1 

34 

.2             0.3               5.0               (I.!) 

" 

Medium 

721 

5S5       SI 

44 

7.7               0.2               1.1 

" 

Large1 

834 

024      75 

40 

.3             0.5               5.4               ().!) 

The  usefulness  of  the  above  analyses  has  been  very  great,  and 
therefore  at  my  request  Dr.  Frankel  has  made  similar  analyses  of 
lemons.  In  them  the  percentage  of  sugar  is  strikingly  low,  but  it 
should  be  remembered  that  citric  acid  can  turn  to  sugar  in  the  body. 
Recently,  I  have  given  the  sixteenth  of  a  lemon  to  patients  for  their 
spinach  and  salads  instead  of  an  indefinite  quantity  of  vinegar.  One 
patient  who  persisted  in  showing  sugar  used  70  c.c.  of  vinegar  at  a 
meal. 

TAHI.K    130. — ANALYSES  OK  LKMO.NS. 


Sold  as 


Gross 

Edible 

Grams  <  f 

Percentage 

Total 

Percentage 

weight. 

porti 

on, 

sugar  as 

of  edible 

of  edible 

grams. 

grams. 

f; 

glucose. 

portion. 

citric  acid, 
grains. 

portion. 

92 

50 

54 

0.570 

1  .  15 

3.  10 

0.20 

!)() 

42 

17 

0.51s 

1.20 

•>  ,s;.j 

0.  75 

87 

GO 

09 

0.459 

0.77 

3  .  S2 

0.35 

California 

California 
Messina    . 


(5)  Jidnanax. —  Bananas  can  seldom  be  taken  by  diabetic  patients 
because  the  content  of  carbohydrate  is  so  high,  being  equivalent 
to  that  in  potato.  In  general  the  riper  a  banana,  and  for  that 
matter  any  vegetable  or  fruit,  the  more  the  starch  in  it  has  changed 
to  sugar,  and  also  the  more  carbohydrate  it  contains.  Siiue  1111- 
ripened  fruits  with  their  lower  carbohydrate  content  can  be  made 
palatable  by  cooking,  a  way  is  afforded  for  diabetic  patients  to  use 
them. 

(0)  Ripe  (Hires. — Ripe  olives  make  a  pleasing  change  in  the  diet. 
They  contain  4.0  per  cent,  carbohydrate  in  contrast  to  green  olives, 
which  contain  1  .s  JUT  cent.  Furthermore,  ripe  olives  are  more 
easily  digested.  Five  ripe  or  ten  green  olives  contain  1  gram  carbo- 

1  Greener  than  the  others. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  267 

hydrate  and  a  ripe  olive  contains  a  gram  and  a  green  olive  half  a 
gram  of  fat.    The  quantity  of  protein  in  ten  olives  is  about  1  gram. 

(7)  Milk. — The  carbohydrate  in  milk  is  in  the  form  of  lactose  and 
can  be  reckoned  at  5  per  cent,  or  1.5  grams  per  30  c.c.,  or  1  ounce. 
It  is  the  same  in  skimmed  milk  and  whey;  but  cream  and  koumiss 
contain  about  3  per  cent.,  or  1  gram  carbohydrate  to  the  ounce. 
Buttermilk  contains  essentially  the  same  quantity  of  carbohydrate 
and  protein  as  milk,  but  only  a  trifling  amount  of  fat.     I  cannot 
understand  why  doctors  so  frequently  give  it  to  their  patients. 

(8)  Oatmeal. — Oatmeal  is  two-thirds  carbohydrate.    In  calculations 
one  should  always  be  guided  by  the  dry  weight,  because  the  different 
preparations  vary  greatly  in  bulk  and  weight  when  cooked.     (See 
Table  105,  p.  375.)     The  subject  of  the  oatmeal  treatment  is  dis- 
cussed at  length  on  page  367. 

(9)  Bread. — The  carbohydrate  in  white  wheat  bread  amounts  to 
about  53  per  cent.    If  the  bread  is  toasted,  enough  water  is  lost  to 
raise  the  percentage  of  carbohydrate  in  the  toast  to  about  60  per 
cent.     If  the  bread  is  made  without  sugar  and  with  water  instead 
of  milk  the  carbohydrate  content  is  lowered  and  may  amount  to 
only  45  per  cent.     Coarse  breads  if  made  without  sweetening  or 
milk  would  contain  slightly  less  carbohydrate.     It  is  undesirable 
to  give  bread  to  diabetic  patients  unless  their  tolerance  is  very  high, 
because  they  can  take  so  little  without  causing  glycosuria  that  the 
bread  is  simply  an  aggravation.    An  error  in  weight  of  1  ounce  of  a 

5  per  cent,  vegetable  amounts  to  1  gram  carbohydrate,  of  potato  to 

6  grams,  but  of  bread  to  IS  grams.     Crackers  and  zweiback  contain 
still  less  water  than  toast,  and  in  consequence  the  percentage  of 
carbohydrate  is  raised  to  the  neighborhood  of  70  per  cent. 

Diabetic  breads  are  discussed  on  page  505. 

3.  Protein. — The  quantity  of  protein  required  by  diabetic  patients 
varies  with  the  age,  weight,  and  activity  of  the  case  as  well  as  with 
condition  of  the  kidneys.  It  is  a  safe  rule  at  the  beginning  of  treat- 
ment to  attempt  to  increase  the  protein  gradually  up  to  the  same 
quantity  as  that  required  by  a  normal  individual. 

Chittenden1  points  out  that  60  grams  (one-half  the  old  protein 
standard)  protein  is  quite  sufficient  to  meet  all  the  real  physiological 
needs  of  the  body  under  ordinary  conditions  of  life  and  with  most 
individuals  not  leading  an  active  out-of-door  life,  even  smaller 
amounts  will  suffice.  Chittenden,  weighing  57  kilograms,  and 
Mendel,  weighing  70  kilograms,  lived  respectively  on  34  and  41 
grams  protein  daily,  the  former  for  nine  and  the  latter  for  seven 
months.  However,  as  suggested  by  Allen  in  his  recent  Harvey 
Lecture,  the  protein  must  not  be  too  low,  because  it  is  probable  that 

Chittenden:  Physiological  Economy  in  Nutrition,  Frederick  A.  Stokes  Company, 
New  York,  1904. 


2()S  DIET  IN  HEALTH  AND  L\   DIABETES 

upon  a  low  protein  ration  fat  is  not  as  well  tolerated,  particularly 
if  carbohydrate  be  restricted.  Intil  the  Chittenden  low  protein 
diet  is  proved  to  be  entirely  satisfactory  for  healthy  individuals 
over  a  long  period  of  years  it  is  best  not  to  have  recourse  to  it  for 
long  periods  in  the  treatment  of  diabetes.  Temporarily  small 
quantities  may  be  given,  but  safety  lies  not  far  from  1  gram  protein 
to  each  kilogram  body  weight.  A  quantity  of  protein  above  the 
usual  amount,  on  the  other  hand,  is  undesirable  for  two  reasons: 
(1)  It  increases  the  metabolism  of  the  diabetic  patient  just  as  in  the 
normal  individual.  This  is  unfortunate,  for  the  diabetic  metabolism 
is  sufficiently  stimulated  without  the  need  of  further  stimulation 
by  protein.  (2)  Furthermore,  in  the  severer  cases  of  diabetes  it 
increases  the  quantity  of  sugar  in  the  urine.  Reference  has  already 
been  made  to  the  excessive  quantities  of  protein  ingested  by  diabetic 
patients  when  living  upon  an  unprescribed  diet  (see  page  253),  and 
will  be  made  to  the  similarly  large  quantities  of  protein  metaboli/ed 
both  by  patients  in  the  course  of  acid  intoxication  (see  page  35(>) 
and  rarely  during  the  course  of  fasting  when  inanition  is  extreme 
(Case  No.  1190,  p.  379). 

It  has  been  claimed  that  vegetable  proteins  give  rise  to  less 
carbohydrate  in  the  diabetic  organism  than  do  animal  proteins.  As 
a  matter  of  fact,  carbohydrate  may  be  formed  out  of  any  protein. 

Janney1  has  studied  the  formation  of  glucose  from  protein  in 
diabetes  by  feeding  pure  proteins  to  fasting,  phlorizinized  dogs. 
lie  found  that  no  difference  existed  in  the  sugar-producing  capacity 
between  animal  and  vegetable  proteins  because  of  their  respective 
origins,  but  that  the  glucose  yielded  in  metabolism  could  be  demon- 
strated to  vary  directly  with  the  amount  of  glucogenetic  amino- 
acids  contained  in  each  individual  protein.  Thus  the  wheat  protein 
gliadin  which  contains  43.7  per  cent,  of  the  highly  glucogenetic 
glutamic acid  yields  80  per  cent,  of  glucose  in  metabolism.  Indeed, 
gliadin  yields  the  largest  amount  of  glucose  of  all  proteins  hitherto 
examined  and  casein  and  ovalbumin  the  least.  The  quantity  of 
glucose  yielded  by  various  proteins  is  shown  in  the  table: 

TABLE   l.'il. — GMTOSK  YIKLDS  OF  INVESTED  PROTEINS  (.JANNEY). 


f'uHcin,     Ovalbumin,      Serum,         (ielntin,         Kibrin, 
pern-lit.       percent.       per  c-cnt.       percent.       percent.       percent.       percent.       percent. 

•is  54  r,r>  r>">  r>:5  r>r>  so  r>:5 

Janney's  work  has  clearly  demonstrated  that,  the  amount  of  sugar 
from  protein  is  dependent  upon  the  glucose-yielding  amino-acids 
of  protein  and  not  upon  the  carbohydrate  content  of  protein, 
which  is  negligible.  His  experiments  showed  that  no  great  variation 

1  Janney:  Arch.  Int.  Met!.,  1916,  xviii,  p.  584. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  269 

existed  in  the  amount  of  glucose  produced  from  muscle  obtained 
from  various  species  of  animal,  including  man,  and  that  the  per- 
centage obtainable  was  58,  corresponding  to  a  glucose-nitrogen 
ratio  of  3.4  to  1.  (See  page  274.) 

It  is  evident  that  closer  attention  should  be  paid  to  this  glucose 
formation  from  protein,  and  that  the  carbohydrate  derived  from 
protein  should  be  added  to  the  carbohydrate  given  as  such  in  the 
diet  in  estimating  the  diabetic's  power  to  burn  carbohydrate.  It 
is  suggestive  that  the  protein  of  white  bread  yields  more  glucose 
than  that  of  other  forms  of  protein,  and  more  also  than  that  of  the 
protein  of  corn  or  rye.  Thus  "the  total  percentile  sugar  yield  of 
white  wheat  bread  is  01 ,  corn  bread  50,  and  rye  44  per  cent."  These 
data  are  also  interesting  when  applied  to  diabetic  breads  and  also 
to  patent  diabetic  foods,  for  although  these  may  contain  a  small 
quantity  of  carbohydrate,  yet  the  protein  in  them  is  high  and 
capable  of  furnishing  a  large  amount  of  glucose.  The  result  is  that 
such  commercial  products  may  thus  actually  produce  as  much 
glucose  in  a  diabetic  as  does  ordinary  bread.  However,  one  must 
not  be  wholly  governed  by  analytical  conditions,  as  Janney  has 
pointed  out,  for  although  vegetable  and  animal  protein  yield  glucose 
according  to  their  content  of  amino-acids,  it  is  quite  possible  that 
the  vegetable  proteins  will  be  less  well  digested  owing  to  the  form 
in  which  they  are  eaten,  and  thus  less  protein  is  assimilated,  and  in 
consequence  less  glucose  formed. 

"  It  seems,  in  view  of  these  new  results,  scarcely  a  wise  procedure 
to  strive  to  eliminate  every  gram  of  carbohydrate  from  the  diabetic's 
diet,  inasmuch  as  nearly  two-thirds  of  the  proteins  fed  are  found  to 
be  converted  into  glucose  in  course  of  metabolism  by  the  diabetic." 

The  inaccuracy  of  the  usual  methods  of  analysis  of  protein  has 
been  shown  by  Janney.1  Whether  the  protein  has  been  determined 
by  extraction  or  difference,  large  quantities,  even  13  per  cent,  of 
non-protein  substances  have  been  reckoned  as  protein.  Further- 
more, the  carbohydrate  content  of  muscle,  although  small,  has 
been  reckoned  as  protein,  and  it  is  not  certain  that  the  extraction 
of  fat  has  been  complete.  By  new  methods  of  analysis  he  has 
determined  that  the  protein  in  the  muscles  of  chicken,  fish  (halibut), 
ox,  rabbit,  cat,  dog  and  man  varies  between  16.3  and  18.8  per  cent. 
Thus,  the  amount  of  protein  calculated  by  the  older  methods  is 
seen  to  exceed  that  determined  by  the  new  analyses  from  15  to 
20  per  cent.,  in  all  cases.  The  calculation  of  values  for  proteins  in 
meat  should  be  revised.  Quite  likely  I  have  estimated  too  high  the 
protein  in  meat  and  the  error  has  been  compensated  by  my  dis- 
regard of  the  protein  in  broths  and  gelatin. 

1  Janney:  Jour.  Biol.  Chern.,  1916,  xxv,  p.  185. 


270  DIET  IN  HEALTH  AND  IX  DIABETES 

(a)  Meat  and  Fish. — The  chemical  composition  of  meat  and  fish 
is  simplified  by  the  fact  that  except  in  liver  and  shell-fish,  carbo- 
hydrate is  absent.  Even  in  liver  the  quantity  of  carbohydrate  is 
almost  negligible  when  \ve  consider  the  amount  and  frequency  with 
which  this  article  of  food  is  eaten.  The  analyses  of  liver  and  shell- 
fish will  be  found  in  the  tables. 

The  chief  difficulty  in  computations  of  the  nutritive  value  of  meat 
and  fish  is  due  to  the  varying  content  of  fat.  Thus,  the  edible 
portion  of  chicken  may  contain  on  the  average  only  2.5  per  cent, 
of  fat,  whereas  lean  ham  may  contain  14  per  cent,  of  fat,  fat  ham 
as  much  as  50  per  cent.,  and  smoked  bacon  05  per  cent.,  though 
lean  smoked  bacon  42  per  cent.  It  is  obvious,  therefore,  that  with- 
out accurate  analyses  of  the  fat  in  meat,  only  an  approximate  idea 
can  be  had  of  its  caloric  value,  and  as  such  analyses  can  seldom  be 
performed  this  seriously  invalidates  all  our  reckoning  of  the  day's 
diet.  In  general,  a  mixture  of  cooked  lean  meats  probably  contains 
not  far  from  10  to  15  per  cent,  of  fat. 

Fish  differs  from  meat  chiefly  in  the  small  quantity  of  fat.  Fven 
salmon,  which  contains  more  fat  than  most  other  fish,  showed  in 
its  analysis  only  12.S  per  cent,  fat,  shad  9.5  per  cent.,  and  herring 
and  mackerel  7.1  per  cent.  In  general,  other  kinds  of  fish  show 
0  per  cent,  or  less  of  fat.  Halibut  steak,  for  example,  contains 
5.2  per  cent.,  and  cod  0.4  per  cent.  Preserved  fish,  however,  is 
quite  rich  in  fat:  thus  sardines  contain  19.7  per  cent.  In  sub- 
stituting fish  for  meat,  my  patients  are  taught  to  add  from  one- 
half  to  one  teaspoonful  of  olive  oil  to  the  diet  for  each  )>0  grams  of 
fish. 

The  quantity  of  protein  in  meat  also  varies  considerably  and 
usually  falls  as  the  percentage  of  fat  rises.  A  value  of  20  per  cent, 
for  protein  in  uncooked  lean  meat  represents  about  the  average, 
and  this  is  increased  to  25  per  cent,  or  more  when  the  meat  is  cooked. 
The  quantity  of  protein  in  fish  is  very  slightly  less  than  that  in 
meat.  Fish  is  especially  desirable  in  the  early  days  of  protein 
feeding  following  the  preliminary  carbohydrate-feeding  days, 
because  in  fish  the  quantity  of  fat  is  so  low.  Shell-fish  make  agree- 
able additions  to  the  diet:  (1)  they  are  desirable  because  they  are 
palatable;  (2)  they  are  bulky  foods  and  so  are  satisfying;  (o)  they 
furnish  a  separate  course  at  a  meal.  Half  a  do/en  oysters  or  clams 
are  quite  sufficient.  The  edible  portion  of  a  medium-sized  oyster 
on  the  shell  weighs  on  the  average  half  an  ounce,  and  half  a  do/en 
oysters  would  amount  to  90  to  100  grams.  The  six  would  contain 
about  (')  grains  protein,  1  gram  fat,  and  4  grains  carbohydrate- 
tile  equivalent  of  50  calories.  Half  a  do/en  clams  on  the  shell 
(edible  portion)  weigh  i>5  grams  and  contain  0.7  gram  carbohydrate, 
•'!  grams  protein,  and  a  negligible  quantity  of  fat. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  271 

(b)  Broths. — Broths  are  so  extensively  used  upon  fasting  days 
in  the  treatment  of  diabetes  that  their  composition  deserves  notice. 
In  the  Composition  of  American  Food  Materials,  Bull.  28,  T.  S. 
Dept.  of  Agriculture,  the  average  of  three  analyses  of  bouillon  shows 
it  to  contain  protein  2.2  per  cent.,  fat  0.1  per  cent.,  carbohydrate 
0.2  per  cent.  This  is  based  on  the  supposition  that  all  the  nitrogen 
is  present  in  the  form  of  protein,  which  all  understand  is  not  actually 
the  case.  It  is  apparent  that  patients  taking  one  quart  of  bouillon 
or  broth  in  a  day  must  get  considerable  nitrogenous  material. 
Frequently  bouillon  cubes1  are  used  by  patients.  These  consist  chiefly 
of  common  salt;  the  amount  of  meat  extract  present  ranges  from 
8  ]XT  cent,  to  28  ]>er  cent.;  and  the  third  important  ingredient  is 
plant  or  vegetable  extract,  which  constitutes  from  3  to  30  per  cent. 

In  a  research  with  Iliche  upon  the  metabolism  of  ammo-acids, 
Lusk2  had  occasion  to  investigate  the  nutritive  value  of  Liebig's 
Extract  of  Beef.  As  a  result  of  his  metabolism  experiments  upon 
fasting  dogs  in  the  calorimeter,  he  reached  the  conclusion  that 
"Liebig's  Extract  is  without  influence  upon  the  metabolism  in 
spite  of  the  glandular  activity  it  is  known  to  induce." 

Reference  is  made  on  page  284  to  the  large  quantity  of  salt  in  the 
broth  prepared  at  the  Xew  England  Deaconess  Hospital,  and  the  full 
analysis  of  the  broth  is  there  given.  Believing  the  matter  of  still 
greater  importance,  I  enlisted  the  help  of  Professor  Mendel,  and 
through  him  analyses  of  various  broths  in  use  in  small  and  large 
hospitals  in  Boston  have  been  made  by  Mr.  A.  II.  Smith,  of  Xew 
Haven,  Conn.  These  are  given  in  Table  132. 

The  table  shows  that  the  quantity  of  salt  in  the  broths  is  quite 
considerable  and  that  it  varies  markedly  in  the  different  broths. 
One  quart  of  broth  at  one  hospital,  for  example,  would  contain 
20  grains  of  salt,  while  at  another  less  than  1  gram. 

It  is  satisfactory  to  record  that  all  broths  agree  in  being  free  from 
carbohydrate.  It  becomes  evident,  therefore,  why  edema  is  so  apt 
to  occur  during  the  course  of  modern  diabetic  treatment.  The 
quantity  of  salt  in  broths  should  certainly  not  exceed  ().")  ]>er  cent. 

The  percentage  of  fat  in  the  broth  as  shown  by  the  ether  extract 
is  almost  invariably  slight.  The  broth  ( '-1 ,  in  which  the  percentage 
was  so  considerable,  was  a  sample  sent  from  the  hospital  kitchen 
to  the  diet  kitchen;  but  it  did  not  represent  the  actual  form  in 
which  the  broth  was  served  the  patients. 

The  variation  of  the  total  nitrogen  in  the  broths  is  marked  and  is 
the  most  important  feature  brought  out  by  these  analyses.  Here 
again  it  should  be  remembered  that  the  higher  analyses  represent 
broths  submitted  for  examination  to  Mr.  Smith,  and  that  if  the 


272 


DIET  IN   HEALTH   AND   IN   DIABETES 


THE   DIET   OF   DIABETIC   INDIVIDUALS  273 

sediment  of  the  broths  as  well  as  the  fat  were  removed  the  values 
for  nitrogen  would  not  only  be  less  but  also  more  uniform.  It  \\ill 
be  seen  that  in  broth  I)-2  over  10  grams  of  nitrogen  were  present 
to  the  liter,  and  that  the  protein  nitrogen  in  this  broth  amounted 
to  (>1  per  cent,  of  the  total.  In  general,  it  is  a  safe  statement  to 
make  that  nearly  three-quarters  of  the  total  nitrogen  in  broths  is 
made  up  of  protein-  and  amino-nitrogen.  Such  a  large  quantity 
of  protein  demands  cognizance  and  must  be  allowed  for  in  any 
dietetic  computations.  It  is  notable  that  the  broths  with  high  values 
for  nitrogen  were  broths  from  private  hospitals  and  were  the  broths 
usually  given  all  the  hospital  patients  rather  than  to  diabetic 
patients.  It  is  obvious,  therefore,  that  broths  for  diabetic  patients 
should  be  prepared  in  a  different  manner  than  the  rich  broths  for 
other  patients  who  are  often  overfed  with  design. 

In  general,  therefore,  thin,  clear  meat  broths,  agreeably  seasoned, 
lightly  salted,  can  be  considered  desirable  for  diabetic  patients. 
If  the  broths  are  concentrated,  form  a  jelly  when  cold,  are  served 
without  complete  removal  of  the  fat  and  the  sediment,  they  are 
unsuitable  and  will  seriously  impair  the  value  of  dietetic  calculations, 
and  undoubtedly  such  broths  have  repeatedly  prolonged  the  periods 
required  to  make  patients  sugar-free. 

(c)  Increased  Assimilability  of  Carbohydrate  in  Absence  of  Protein. 
—The  effect  of  a  low  protein  diet  upon  the  assimilation  of  carbo- 
hydrate was  first  strikingly  brought  out  by  Klemperer.1  His 
experiments  were  performed  with  dextrose,  and  he  showed  that  even 
dextrose  would  be  assimilated  to  a  considerable  degree  by  a  severe 
diabetic  patient  provided  the  protein  in  the  diet  was  low.  He  gave 
!")()  grams  of  dextrose  to  a  diabetic  patient  while  upon  diets  con- 
taining varying  quantities  of  protein.  Klemperer 's  data  are  shown 
in  the  following  table: 

TABLE  133. — KXCRETIOX  OF  DEXTROSE  BY  A  DIABETIC  AFTER  IXGESTIOX 
OF  lot)  CRAMS  DEXTROSE  WITH  VARYING  AMOUNTS  OF  PROTEIX. 


Excretion  of  dextrose, 
grains.  «ram.-. 

10  31 

00  37 

110  5(5 

Clinicians  of  the  older  school,  beginning  with  Cantani,  appre- 
ciated the  importance  of  restricting  the  quantity  of  protein. 

The  tendency  has  been,  however,  to  restrict  the  protein  far  more 
than  these  authorities  advocated,  and  it  has  not  seldom  occurred 
in  my  own  experience  that  I  have  allowed  my  patients  too  little 
rather  than  too  much  protein.  Naunyn,  for  example,  frequently 
mentions  12o  gram.,  protein  (20  grams  nitrogen)  (.100  grains  cooked 

1  Klemperor:  Die  Therap.  dor  ( Jegenwart ,  1911,  Hi,  p.  447. 

18 


274  DIET  IX   HEALTH   AND   I\r   DIABETES 

=  025  grains  uncooked  meat)  in  the  dietaries  of  his  patients,  but 
I  am  inclined  to  believe  he  usually  employed  a  somewhat  smaller 
amount.  The  deciding  factor  is  the  tolerance  of  the  diabetic  for 
protein,  and  this  should  be  determined  just  the  same  as  is  the  toler- 
ance for  carbohydrate.  It  should  furthermore  be  determined  in  the 
presence  of  carbohydrate  and  fat  as  well.  Protein  is  indispensable 
to  a  diabetic,  and  his  tolerance  for  carbohydrate,  fat,  and  alcohol 
must  bo  subservient  to  it.  The  chief  source  of  carbohydrate  in 
protein  is  to  be  found  in  the  amino-acids  therein  contained.  Event- 
ually a  protein  may  be  found  in  which  the  amino-acids  containing 
an  uneven  number  of  carbon  atoms,  which  are  the  ones  giving  rise 
to  sugar,  are  especially  low,  but  at  present  the  differences  in  this 
regard  in  different  proteins  are  not  of  great  importance,  yet  Janney's 
analyses  should  be  borne  in  mind.  See  Table  131.  Unfortunately,  if 
we  avoid  the  amino-acids  with  uneven  numbers  of  carbon  atoms  and 
give  those  with  an  even  number  of  carbon  atoms,  we  are  offering 
our  patient  good  material  for  the  formation  of  /3-oxy butyric  acid. 
It  has  been  said  that  the  more  slowly  a  given  variety  of  protein  is 
absorbed  the  less  likely  it  is  to  give  rise  to  sugar.  This  quality  may 
be  the  deciding  factor  after  all. 

(<7)  Dextrose-nitrogen  Ratio. — The  quantity  of  dextrose  which 
can  be  formed  from  the  protein  molecule  has  already  been  discussed 
on  page  130.  In  dietetic  computations  I  think  it  safest  to  consider 
the  maximum  quantity  of  sugar  in  the  urine  which  can  be  attributed 
to  the  protein  in  the  diet  to  be  ('>()  per  cent.,  which  is  Lusk's  dextrose- 
nitrogen  ratio  (I)  :  N)  3.05  grams  dextrose  :  1  gram  nitrogen. 
If  3.05  grams  dextrose  are  divided  by  0.25  grams  protein  (the 
equivalent  of  1  gram  nitrogen)  the  quotient  is  58.4  per  cent.  For 
convenience  in  clinical  computations  the  value  00  per  cent,  may  be 
employed.  Lusk  obtained  these  figures  working  with  phlominized 
dogs.  Janney,  working  with  more  recent  analytical  methods,  finds 
the  ratio  3.4  :  1.  From  the  above  it.  is  easily  understood  how 
sugar  may  IK;  found  in  the  urine  of  diabetic  patients,  although 
carbohydrates  are  excluded  from  the  diet.  On  the  other  hand, 
Lusk  points  out  that  the  quantities  of  sugar  in  the  urine  in  excess 
of  the  ratio  of  3.05  grams  dextrose  for  1  gram  nitrogen,  are  an 
indication  that  the  patient  is  taking  carbohydrate  and  so  far  all  my 
data  support  this  view.  The  theoretical  maximum  of  carbohydrate 
which  can  be  formed  from  protein  is  S3  per  cent. 

Lusk  also  found  the  same  1)  :N  ratio  in  the  case  of  a  severe 
diabetic,  and  he  has  termed  a  1)  :N  ratio  of  3.05  :  1  the  fatal 
diabetic  ratio,  but  further  study  of  this  ratio  showed  him  that  it 
is  not  necessarily  of  fatal  omen.1  Mikowski  found  that  2.05  grams 

i  Lusk:  Arch.  Int.  Mod.,  1909,  iii,  p.  1. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  275 

of  dextrose  appeared  in  the  urines  of  his  depancreatized  dogs  for 
each  gram  of  nitrogen,  thus  giving  a  D  :  N  ratio  of  2. (55  :  1. 

(e)  The  Carbohydrate  Balance. — The  carbohydrate  balance  repre- 
sents the  difference  between  the  total  quantity  of  carbohydrate 
ingested  in  the  diet  and  the  sugar  excreted  in  the  urine  during  the 
same  period.  When  the  quantity  of  carbohydrate  in  the  diet  is 
greater  than  the  quantity  of  sugar  in  the  urine  the  patient  is  said 
to  have  a  positive  carbohydrate  balance.  When  the  carbohydrate 
in  the  diet  is  less  than  the  quantity  of  sugar  in  the  urine  the  carbo- 
hydrate balance  is  said  to  be  minus  or  negative.  Under  the  latter 
circumstances  it  is  evident  that  the  sugar  in  the  urine  is  derived 
either  from  sugar  stored  in  the  body  or  is  being  formed  out  of  pro- 
tein. If  it  simply  represents  stored-up  sugar,  within  a  few  days  the 
negative  carbohydrate  balance  will  promptly  change  to  zero  and 
perhaps  eventually  to  a  positive  balance.  Case  No.  S  illustrates  this. 

TABLE  134. — THE  CHANGE  IN  THE  CARBOHYDRATE  BALANCE  FROM  NEGATIVE 

TO  POSITIVE.     CASE  No.  8.     AGE  AT  ONSET,  SIXTY  YEARS.     NORMAL 

EXPECTATION  OF  LIFE,  FOURTEEN  YEARS  AND  TEN  MONTHS. 

THE  PATIENT  LIVED  FOURTEEN  YEARS. 

Diac 

Date, 

1S!)9.  grams.        grams,        intake.       balance.        pounds.  Remarks 

June  28     .      .       0  Gl  ?  ?  161          Diabetes  discovered. 

30 

July      1 
2 

1900 
Jan.      1     ....  4  45  +41  174 

1909 

Oct.    12     .      .    +  +  19  54  +35  ..  Carbuncle. 

17     .      .       +  0  70  +70 

21     .      .       0  0  70  +70  140 

1911 
May  18     .      .       0  42  05  +23  .  .  Pneumonia. 

1912 
Sept,  11     .      .       0  10  30  +20  143 

1913 

April  20     ....  21  ?  140'         Ilemiplesia. 

June  17  .      ..  2.49c  ?  ••  ••  Pneumonia;  died. 

This  moderate  case  of  diabetes  first  came  under  observation  June 
28,  1899,  and  for  the  first  twenty-four  hours  during  which  the  urine 
was  collected  the  intake  of  carbohydrate  was  not  known.  Upon 
the  following  day  no  carbohydrate  at  all  was  administered,  but 
sugar  had  existed  for  so  considerable  a  period  in  the  body  that 
time  was  necessary  for  its  excretion.  The  minus  carbohydrate 
balance  of  (55  grams,  therefore,  was  simply  due  to  retained  sugar  in 
the  body.  This  is  plainly  shown  because  upon  the  following  day, 
when  10  grams  carbohydrate  were  allowed,  the  sugar  in  the  urine 

1  March  23. 


Diacetie 
acid, 
grams. 

Sugar  in 
urine, 
grams. 

Carbo- 
hydrate 
intake. 

Carbo- 
hydrate 
balance. 

Weight, 
pounds. 

0 

01 

? 

? 

161 

0 

65 

0 

-05 

0 

13 

10 

-   3 

0 

0 

10 

+  10 

270  DIET  IX   HEALTH   AXD   IX   D1AHETEH 

decreased  to  13  grams,  constituting  a  minus  carbohydrate  balance 
of  3  »'rams;  but  a  day  later  upon  the  same  diet  the  urinary  sugar 
completely  disappeared  and  the  carbohydrate  balance  was  plus 
10  grams.  Six  mouths  later  the  tolerance  for  carbohydrate  had 
risen  to  41  grams.  It  rose  somewhat  during  the  subsequent  years, 
persisted  during  a  carbuncle,  fell  \vitli  an  attack  of  pneumonia, 
then  again  fell,  and  in  1!H3  the  patient  died  of  a  second  attack  of 
pneumonia  three  months  after  a  cerebral  hemorrhage  in  the  four- 
teenth year  of  the  disease. 

On  the  other  hand,  a  minus  carbohydrate  balance  which  is  per- 
sistent is  indicative  of  severe  diabetes  with  the  formation  of  sugar 
from  protein.  The  severity  of  the  diabetes  in  such  a  case  is  also 
shown  by  the  fact  that  when  a  minus  carbohydrate  balance  is 
permanently  present,  acidosis  is  extreme.  (See  Case  No.  344,  page 
410.)  It  will  be  seen  that  the  carbohydrate  balance  was  minus 
on  .lime  2S,  and  .Inly  4,  0,  10  and  later  remained  at  quite  a  uniform 
figure,  although  the  carbohydrate,  intake  was  varied  to  a  considerable 
degree,  but  increased  along  with  the  severity  of  the  diabetes.  1  hiring 
the  period  represented  by  these  four  days,  extending  considerably 
over  a  year  and  a  half,  the  quantity  of  nitrogen  was  not  very  far 
from  1C)  grams,  and  with  allowance  for  fecal  nitrogen  might  be 
taken  as  IS  grams,  representing  the  metabolism  of  approximately 
112  grams  protein.  From  this  enough  sugar  could  be  formed  to 
account  for  the  minus  carbohydrate  balance  if  00  grams  of  sugar 
are  derived  from  100  grams  protein  in  accordance  with  Lusk's 
I)  :  N  ratio  of  3.05  :  1.  In  like  the  temporary  minus  balance  in  Case 
No.  S,  it  will  be  seen  that  the  minus  carbohydrate  balance  in  Case 
Xo.  344  was  persistent  and  in  consequence  the  acidosis  was  extreme. 
The  remarkable  change  in  the  carbohydrate  balance  toward  the  end 
of  life  took  place  after  the  patient  had  developed  diffuse  tuberculosis 
and  was  about  to  die.  Attention  is  called  especially  to  the  disap- 
pearance of  acidosis  at  thi>  time.  It  is  referred  to  in  the  discussion 
of  Allen's  theories  of  diabetes,  under  treatment,  and  again  in  the 
section  upon  tuberculosis. 

Finally,  Case  Xo.  70.")  illustrates  the  favorable  change  which 
takes  place  in  the  carbohydrate  balance  with  modern  treatment  and 
at  the  same  time  the  variability  in  the  1 )  :  X  ratio.  (See  page  314.) 

4.  Fat.-  Fat  in  any  form  is  absorbed  by  the  diabetic  patient 
quite  as  well  as  by  normal  individuals,  except  in  those  rare  cases  of 
pancreatic  diabetes.  One  such  case  (XV).  070)  was  seen  by  me  a 
few  days  before  coma.  In  this  instance  diabetes  occurred  after 
partial  loss  of  the  gland  from  acute  pancreatitis.  The  case  is 
reported  in  detail  by  .Jurist.1 

1  Jurist:  Am.  Jour.  Mod.  Sr\,  I'.tOO,  rxxxviii,  p.  180. 


THE   DIET  OF   DIABETIC   INDIVIDUALS  277 

Fat,  however,  is  not  well  absorbed  by  the  dog  made  diabetic  by 
the  removal  of  the  pancreas.  This  fact  solves  one  of  the  problems 
experienced  in  producing  acidosis  in  dogs.  When  Allen  succeeded 
in  making  a  dog  with  severe  diabetes  gain  or  even  hold  his  weight 
by  forced  feeding  of  fat,  increasing  acidosis  occurred.1 

The  experiments  of  Ringer,2  in  Lusk's  Laboratory,  are  against 
the  formation  of  even  trifling  quantities  of  sugar  from  fat,  and 
in  this  respect  correspond  with  the  general  consensus  of  opinion  in 
the  literature.  In  a  careful  study  of  three  severe  cases  of  diabetes 
Allen  and  DuBois3  reach  the  same  conclusion. 

Although  fat  is  absorbed  quite  as  well  by  the  diabetic  as  by  the 
normal  individual,  on  the  other  hand,  it  would  be  incorrect  to  say 
that  it  was  as  well  utilized.  This  is  due  to  the  formation  and  ex- 
cretion of  /3-oxybutyric  acid  in  severe  diabetes.  Although  all  of 
this  acid  may  not  come  from  fat,  the  greater  portion  of  it  does. 
Undoubtedly  future  investigations  will  show  whether  this  acid  comes 
in  great  part  from  fat  soon  after  it  is  eaten  or  whether  it  represents 
in  part  the  breaking  down  of  body  fat. 

Reference  has  already  been  made  to  the  difficulty  of  determining 
the  quantity  of  fat  in  the  diabetic  diet.  Eggs  vary  in  size  and 
may  contain  5  grams  or  7  grams  fat.  The  fat  in  meat  is  most 
variable.  One  analysis  of  a  combined  sample  of  10  portions  of 
mixed  lean  meat  served  my  diabetic  patients  showed  the  percentage 
of  fat  to  be  15  per  cent.,  and  another  such  analysis  showed  10  per 
cent.  Bacon,  both  cooked  and  uncooked,  shows  wide  differences 
in  its  content  of  fat. 

(a)  The  Increased  Assimilability  of  Carbohydrate  in  Absence  of  Fat. — 
Notwithstanding  that  sugar  is  not  formed  from  fat,  the  addition  of 
fat  to  a  diet  upon  which  a  severe  diabetic  patient  is  sugar-free  can 
easily  be  followed  by  the  appearance  of  sugar  in  the  urine,  and  the 
converse  is  equally  true.     It  would  seem  as  if  the  fat  molecules 
displaced  the  sugar  molecules  from  their  attachments  in  the  body 
and  set  them  free  for  excretion.     The  increase  of  sugar  following 
the  addition  of  fat  to  the  diet  is  well  shown  in  Case  Xo.  513,  Table 
Xo.  1(10,  p.  354,  for  the  period  extending  between  August  12-13 
to  Aug.  19-20,  and  in  Case  Xo.  1120,  p.  338.     (See  also  Table  136.) 

(b)  The  Value  of  Fat  to  the  Diabetic. — Fat  forms  the  bulk  of  the 
diabetic  patient's  diet.     Even  with  the  most  modern  ideas  upon 
treatment    this    statement    holds.      The    figures    inserted    above 
(page   244)    gave    the    proportions   which  the  different  foodstuffs" 
take  in  the  diet  and  shows  the  extent  to  which  diabetic  patients 
must  depend  upon  fat  to  offset  the  loss  of  carbohydrate.    Remem- 

1  Allen:  Am.  Jour.  Med.  Sc.,  1917,  cliii,  p.  313. 

"  Ringer:  Jour.  Exp.  Med.,  1910,  xii,  p.  105. 

3  Allen  and  DuBois:  Arch.  Int.  Med.,  1916,  xvii,  p.  1010. 


27S  DIET    IN   HEALTH   AND   IN   DIABETES 

Ixring  that  the  diet  of  n  healthy  individual  of  70  kilograms  at 
office  work  contains  approximately  300  grains  carbohydrate,  yielding 
300  X  4)  1200  calories,  and  if  nearly  all  this  quantity  is  unutilized 
by  the  diabetic  patient,  it,  can  be  calculated  ho\v  many  calories  in 
the  form  of  fat  must  be  given  to  replace  it.  Theoretically,  these 
133  grams  -f,1"-  fat  should  be  taken  in  addition  to  the  usual  100 
grams  of  fat  in  the  normal  ration;  but  practically  this  is  seldom 
necessary,  because  the  diabetic  patient  is  usually  less  active  than 
tin'  ordinary  individual  and  the  quantity  of  carbohydrates  which 
we  have  allowed  for  the  normal  individual  may  l>e  in  excess.  Further- 
more, most  dialn'tic  patients  have  a  tolerance  for  quite  a  considerable 
quantity  of  carbohydrate.  Finally,  tliest;  calculations  are  made 
for  a  patient  weighing  70  kilograms.  In  reality  most  diabetic 
patients  weigh  far  less  and  therefore  require  less  food. 

It  is  surprising  how  readily  in  the  past  double  and  even  treble 
the  quantity  of  fat  ingested  by  normal  individuals  was  borne  by 
the  stomach  of  the  diabetic  patient.  Jt  is,  however,  unwise  to  push 
the  administration  of  fat  too  energetically  for  fear  of  causing  a 
dislike  for  it  or  even  indigestion.  I  once  prevented  a  diabetic  boy 
from  enjoying  and  deriving  benefit  from  sardines,  with  their  accom- 
panying oil,  by  allowing  him  to  eat  the  first  time  as  many  as  he  liked. 
lie  promptly  ate  a  boxful  and  the  disgust  he  then  acquired  for 
sardines  was  never  overcome.  The  diabetic  must  eat  fat,  and  the 
problem  is  to  make  it  harmless  for  him  to  do  so.  Frequently,  I  see 
patients  who  have  taken  large  quantities  of  fat  with  obvious  benefit 
for  long  periods.  Case  No.  X  (p.  275)  must  have  taken  150  grams 
of  fat  daily  for  fourteen  years  and  died  at  the  age  of  seventy-three. 
The  quantity  of  carbohydrate  in  her  diet  for  the  greater  part  of  the 
time  was  far  below  75  grams.  The  fat  could  hardly  be  said  to  have 
done  injury  in  this  case,  for  the  patient  outlived  most  of  her  family. 
Case  No.  93X  (p.  4X5)  soon  became  accustomed  to  fat.  Case  No. 
5(')4,  Table  135,  age  at  onset,  sixteen,  cats  1 70  grams  daily — too  much, 
I  acknowledge.  His  case  is  interesting  because  four  years  ago  he  was 
three  and  a  half  months  in  getting  sugar-free,  and  fora  large  part  of 
the  time  showed  acidosis.  Last  year,  after  four  years  of  diabetes,  he 
took  his  preliminary  examination  for  Harvard.  A  brief  abstract  of 
his  case  is  given  below  to  show  that  even  formerly  patients  some- 
times did  surprisingly  well. 

Case  No.  5(>4  came  under  observation  November  30,  1012,  at  the 
age  of  sixteen,  three  weeks  after  his  onset,  which  occurred  without 
previous  symptoms  after  an  important  football  game.  Volume  of 
urine  eight  quarts  during  the  day.  The  marked  acidosis  at  that  time 

nearly  five  years  ago-  led  me  to  make  very  gradual  changes  in  the 
diet  and  the  sugar  in  the  urine  decreased  from  presumably  more 
than  500  grams  a  day  before  entrance  to  the  hospital  to  230  grains 


THE  DIET  OF  DIABETIC  INDIVIDUALS 


279 


on  the  first  day  after  entrance,  December  1 7-1 8,  1012.  The  patient 
was  discharged,  with  42  grains  of  sugar  in  the  urine  on  February 
1.3-14,  1913.  I'm  lor  the  close  care  of  his  physician  and  a  trained 
diabetic  nurse  he  became  sugar-free  IV larch  31,  1913,  and  has 
remained  sugar-free,  with  the  rarest  exceptions,  since. 


TABLE  135.—  CASE  No.  5f>4. 

THE  COURSE  OF  SEVERE  DIABETES  IN  A  BOY 

OF  SIXTEEN.     TREATMENT  BEGUN  IN  DECEMBER,  1912. 

Uri 

no. 

Date. 

Carbo- 
hydrate 
in  diet, 
grams. 

Sodium 
bicarbo- 
nate, 
grams. 

Naked 

weight, 
pounds. 

Volume.         Diaeetie 
o.o.                  acid. 

Total        Total 
XH3,         sugar 
grains,     (polar.), 

grams. 

1912 

Dec.    17-1S 

5430          4-  4-  + 

230 

160                16              99 

18-19 

5100            si.  + 

5.2           130 

160              16            99 

19-20 

4710            4-  + 

ISO 

135 

16          100 

20-21 

4710             +  + 

190 

125              16            99 

21-22 

4050         +  +  4-  4- 

115 

125              16          100 

22-23 

3S40             +  + 

119 

115              16          100 

23-24        4020           +  +  + 

137 

75              16            99 

1913 

Jan.       1-  2 

4140             +  + 

«S9 

50             20          101 

2-  3 

4440           +  +  + 

115 

50             20 

100 

3-  4 

3420     '      4-  4-  + 

...             75 

50             20 

101 

4-  5 

3120             +  + 

37 

15             20 

103 

5-  6 

4200               + 

143 

1  65             20 

104 

6-  7 

2100         +  +  +  4 

13 

15 

106 

9-10 

2700         4-  +  +  4 

:     3  .  S             49 

40 

102 

Mar.  31 

April     1 

945 

1.1               0 

7-  S 

1240            si.   + 

0 

113 

1914 

Jan.      5 

2000               0 

0 

1915 

April  26 

1SOO                0 

1.0               0 

50 

134  (dressed) 

1916 

Sept.  23 

700 

0.7               0 

129  (dressed) 

Oct.    18-19 

1600               + 

6 

Dec.  20-21 

SOO               0 

0 

134  (dressed) 

1917 

Jan.    25  26  •     1000               + 

1.0               0 

45 

May  1,  1915,  blood  sugar,  0.13  per  cent.;   Sept.  23,  1916,  blood  sugar,  0.13  per  cent. 

The  Eskimos  live  largely  upon  fat.  Their  duration  of  life  can 
hardly  be  known  with  accuracy,  and  many  of  the  men  die  as  a  result 
of  their  hazardous  seafaring  occupations.  The  duration  of  life  of 
the  Eskimo  women  should  furnish  an  interesting  study. 

How  much  fat  should  a  diabetic  patient  eat  ?  Mainly,  from  what  has 
been  and  will  be  recorded  in  the  next  section,  this  does  not  depend 
upon  the  capacity  of  his  digestion.  The  safest  answer  would  be  as 
little  as  possible  above  the  normal  ration  of  100  grams.  Unquestion- 
ably the  quantity  will  vary  from  time  to  time,  and  it  may  increase 


2SO  1)1  KT  IX  HEALTH   AXD  7.V   DIABETES 

with  years  without  detriment  to  the  patient.  Nevertheless,  I  am 
always  glad  to  see  a  diet  with  a  carbohydrate-fat  ratio  of  1  :  2  and 
dread  to  see  one  with  a  ratio  of  1  :  ">  or  more. 

Of  late  fats  have  been  much  restricted  in  the  diet  of  diabetic 
patients,  and  often  more  than  necessary  simply  because  of  a  trace 
of  acidosis.  Repeatedly  one  observes  severe  cases  of  diabetes 
who  at  the  start  show  a  mild  reaction  for  diacetic  acid  following 
the  administration  of  a  few  grams  of  fat,  and  yet  later  these  same 
patie,nts,  with  practically  no  increase  in  carbohydrate,  bear  far 
greater  quantities  of  fat  without  the  slightest  evidence  of  acidosis. 
Thus  Case  No.  !K>X,  cited  in  detail  in  Section  VI,  page  4X5,  illus- 
trates how  the  addition  of  an  egg  to  the  diet  of  a  two-year-old  child 
two  days  after  being  made  sugar-free  caused  the  appearance  of  an 
acidosis  which  was  alarming.  The  supposed  acute  fulminating 
cases  of  diabetes  may  be  acute,  but  I  believe  their  fulminating 
character  to  be  usually  artificial  and  caused  by  the  injudicious 
use  of  fat  as  in  this  little  patient. 

Fat  is  most  agreeably  taken  as  cream,  and  cream  which  contains 
20  per  cent,  butter  fat  is  usually  better  borne  than  a  richer  cream. 
It  is  seldom  advisable  to  allow  more  than  half  a  pint  (240  c.c.)  of 
cream,  although  patients  prefer  to  increase  the  quantity  of  cream 
at  the  expense  of  other  forms  of  fat  in  the  diet.  There  is  no  other 
form  of  food  from  which  a  diabetic  patient  can  derive  more  pleasure 
for  its  caloric  value  and  yet  with  less  harm  to  himself  than  from 
cream.  Half  a  pint  of  20  per  cent,  cream  contains  approximately 
.10  grams  of  fat,  and  yet  the  quantity  of  carbohydrate  in  cream 
of  this  richness  is  but  little  over  S  grams,  and  may  be  estimated 
in  clinical  work  as  X  grams  or  1  gram  to  the  ounce.  Occasionally, 
patients  bear  butter  better  than  cream,  and,  as  a  rule,  fresh  uusalted 
butter  is  preferred.  Obviously,  when  cream  is  increased  in  the  diet 
the  butter  must  be  decreased,  and  rice  ccrxd.  Thirty  grams  of  butter 
contain  2.~>  grains  of  fat,  and  this  is  a  welcome  addition  to  the  diet. 
Oleo  or  butterine  contains  no  sugar  and  has  about  the  same  per- 
centage of  fat  as  butter  and  the  cost  is  approximately  one-half 
that  of  first-class  butter.  Lard,  being  nearly  100  per  cent,  fat 
can  be  used  to  advantage  more  than  it  now  is  in  the  diabetic'.-, 
diet.  Crisco,  also  nearly  100  per  cent,  fat,  is  often  more  welcome 
than  lard,  because  of  its  lack  of  flavor.  Oil  is  an  ideal  diabetic 
food,  because  it  is  a  pure  fat.  Oil  is  so  desirable  for  a  diabetic 
that  I  lieMtate  to  have  a  patient  take  more  than  15  grains  (  1  table- 
spoonful)  lest  he  weary  of  the  same.  If  oil  is  disliked  upon  vege- 
tables it  can  be  taken  in  small  quantities  after  meals  as  a  medicine. 
Hodgson's1  prescription  of  equal  parts  of  olive  oil,  castor  oil,  and 

1  Hodgson:  Jour.  Am.  Mi-d.  AsriD.,  1911,  Ivii,  p.  11S7. 


THE  DIET  OF   DIABETIC  INDIVIDUALS 


2S1 


glycerin  mixed  with  one-tenth  part  gum  arable,  flavored  with  oil 
of  wintergreen,  not  only  tends  to  overcome  the  constipation  for 
which  it  is  intended  but  furnishes  much  nutriment.  I  can  testify 
to  its  usefulness.  Italian  patients  naturally  bear  olive  oil  unusually 
well.  An  Italian  diabetic  patient  under  my  care  at  the  Boston  City 
Hospital  with  typhoid  fever  not  only  passed  through  the  disease 
uneventfully  upon  oatmeal  gruel  and  olive  oil,  but  incidentally 
became  sugar-free  and  developed  no  acidosis.  Olive  oil  forms  an 
excellent  lunch  for  diabetic  patients.  I  frequently  advise  its  use 
upon  retiring.  It  is  the  diabetic  patient's  cough  medicine;  it 
relieves  the  symptoms  of  his  hyperacid  stomach.  Peanut,  corn  or 
cotton-seed  oil  may  be  substituted  if  expense  is  a  factor. 

(c)  The  Danger  of  Fat  to  the  Diabetic. — Fat  is  the  chief  source  of 
the  dreaded  acidosis,  though  to  this  in  lesser  degree  the  ami  no- 
acids  of  the  protein  molecule  with  even  numbers  of  carbon  atoms 
contribute  as  well.  Fat,  therefore,  at  one  time  may  save  the  life 
of  the  diabetic,  but  at  another  period  may  destroy  it.  The  close 
dependence  of  acidosis  upon  a  fat  diet  is  beautifully  shown  by  the 
following  chart : 

TABLE  136. l — THE  DEPENDENCE  OF  ACIDOSIS  UPON  THE  FAT  IN  THE  DIET. 


Urine. 

Diet. 

Date. 

Total 
Vol.,       Diacetic        Nils 
c.c.           aeid.        (Folin), 

Total 
sugar 
(polar.). 

Carbo- 
hydrate, 

Protein, 
grams. 

Fat, 
grams. 

Alcohol. 

Calories. 

grams. 

grains. 

f,  ams. 

1912 

July     5 

1200 

+  +            1.9 

48 

20 

100 

200 

0 

2310 

6 

900 

+  +            2.1 

27 

65 

100 

200 

0 

2500 

27 

2490 

+              0.6 

30 

90 

33 

74 

0 

905 

Aug.     8 

2660 

+  +          2.7 

80 

190 

75 

200 

0 

3000  + 

Oct.    20 

2040 

+            0.6 

45 

64 

75 

30 

12 

1010 

31 

2460 

0             0.3 

38 

45 

75 

30 

12 

949 

Nov.  12 

2160 

0             0  .  5 

56            50 

75 

30 

12 

1913 

Jan.    28 

4080 

h  +  +  1     2.6 

122            35 

100 

200 

0 

2370 

Feb.     2 

3630 

h  +  +        3.0 

152            66 

90 

200 

0 

2150 

June  12 

3600    + 

+  +  +      4.1 

108             90 

100 

200 

0 

2640 

Julv   27 

3630    + 

+  +  +      4.4 

123 

200 

150 

180  + 

0 

3000 

31 

3930    + 

+  +  +      3  .  3 

172          200 

150 

180  + 

0 

3000 

There  is  no  more  potent  agency  in  the  prevention  of  acidosis 
than  the  withdrawal  of  fat  from  the  diet.  The  absence  of  acidosis 
in  totally  depancreatized  animals  and  in  a  human  case  of  pancreatic 
insufficiency  like  that  of  Spriggs  and  Leigh'2  is  to  be  explained  by 
the  non -absorption  of  the  fat  given. 

'  Williams  and  Dresbach:    Am.  Jour.  Mod.  Sc.,  cliii,  1917,  p.  65. 
2  Spriggs  and  Leigh:    Jour.  Am.  Med.  Assn.,  1915,  p.  1952. 


282  DIET  IN  HEALTH  AND  IN  DIABETES 

If  chemists  agreed  that  from  each  of  the  higher  fatty  acids  only 
one  molecule  of  /3-oxy butyric  acid  could  be  formed,  it  would  be 
perfectly  evident  that  the  diabetic  would  be  in  a  little  less  danger 
of  acid  poisoning  if  he  lived  upon  the  fat  of  meat  and  fish  rather  than 
upon  butter  fat,  which  contains  a  number  of  the  lower  fatty  acids. 
1'nanimity  upon  this  point,  however,  does  not  exist.  If  the  vague 
impressions  of  clinical  experience  could  be  trusted,  there  would 
seem  to  be  less  danger  of  acidosis  from  the  fat  of  meat  and  fish 
than  from  butter.  Ordinarily,  according  to  von  Xoorden,  the 
butyric  acid  in  butter  is  not  of  significance  ]>cr  .sr  unless  the  quantity 
of  milk  fat  is  in  excess  of  1  ">()  grams. 

The  remarkable  power  by  which  the  individual  can  gradually 
become  accustomed  to  a  fat-protein  diet  is  well  shown  by  many 
diabetic  patients.  Thus,  Case  No.  o44  took  :>72  grams  of  fat  on  an 
oatmeal  day  September  1  .">-!(),  1010.  The  acidosis  on  this  day  was 
extreme,  as  shown  by  the  excretion  of  27.0  grams  /3-oxybutyric 
acid.  Formerly  many  diabetic  patients  took  100  grams  fat  in  the 
form  of  cream  in  addition  to  that  in  bacon,  butter,  eggs  and  fat  meat. 
Yon  Xoorden's  oatmeal  cure  called  for  200  to  300  grams  butter 
and  one  is  led  to  ask  if  the  simultaneous  ingestion  of  the  large 
quantity  of  carbohydrate  did  not  save  the  patient's  life? 

Allen  has  again  made  us  all  his  debtors  by  a  series  of  experiments 
upon  diabetic  dogs  which  show  the  insidious  way  in  which  fat  is 
harmful  in  the  manner  in  which  it  has  been  customarily  employed 
in  the  treatment  of  diabetes.  "Fat  unbalanced  by  adequate 
quantities  of  other  foods  is  a  poison."1 

f).  Alcohol. — In  no  disease  is  the  employment  of  alcohol  more 
useful  or  more  justifiable,  but  it  cannot  be  taken  with  impunity, 
for  neuritis  rather  easily  develops  in  undernourished  patients. 
Alcohol  furnishes  an  agreeable  form  of  food  in  a  diet  which  is  often 
disagreeable,  and  the  quantity  of  nutriment  which  it  contains  is  by 
no  means  negligible.  Authorities  agree  that  the  patient  can  take 
large  quantities  of  fat  more  readily  in  conjunction  with  alcohol. 
Yet,  notwithstanding  all  the  above,  few  of  my  cases  have  taken 
alcohol  and  still  fewer  take  it  now  than  in  years  gone  by.  This  is 
true  even  when  patients  arc  undergoing  fasting.  Most  diabetic 
patients  require  no  alcohol  and  do  not  take  it,  but  severe  cases  are 
often  heljx'd  by  the  addition  of  l.">  to  '.}()  c.c.  to  the  diet.  Thirty 
cubic  centimeters  of  alcohol  are  to  be  found  in  approximately  (10  c.c. 
of  whisky,  brandy,  rum,  or  gin,  or  .'!00  e.c.  of  most  of  the  sugar-free 
wines.  Thirty  cubic  centimeters  of  alcohol  are  equivalent  to  (oOX~) 
210  calorics.  Few  of  my  patients  ever  take  as  much  alcohol  as  this, 
but  half  the  quantity  will  repliiee  about  .1  per  cent,  of  the  total  diet, 

i  Allen:  Am.  .lour.  Mod.  Sr.,  1917,  cliii,  p.  313. 


THE  DIET  OF  DIABETIC  INDIVIDUALS  283 

and  allows  the  omission  of  -?,-  12  grams  of  fat.  This  does  not 
appear  of  great  moment,  but  it  would  amount  to  2100  calories  in 
twenty  days.  Alcohol  may  he  administered  in  various  forms  which 
are  free  from  sugar.  These  are  specified  in  the  diet  tables  on 
pages  517  and  51S. 

The  use  of  alcohol  to  combat  acidosis  will  be  discussed  under  the 
treatment  of  that  condition,  page  393. 

The  effect  of  alcohol  must  be  more  thoroughly  studied  with  the 
calorimeter.  Allen  and  DuBois1  found  its  ingestion  was  occasionally 
followed  by  respiratory  quotients  higher  than  would  theoretically 
be  expected. 

Fasting  patients  frequently  complain  of  nausea  if  they  are  given 
alcohol,  even  though  it  be  administered  in  dilute  form.  I  have 
been  surprised  to  observe  how  often  they  have  requested  that  the 
alcohol  be  omitted  rather  than  continued.  Then  too  there  is  always 
the  question  as  to  the  effect  of  alcohol  on  the  cells  of  the  body  when 
given  to  a  diabetic  either  with  or  without  food.  I  am  not  convinced, 
looking  at  it  from  this  point  of  view,  that  it  is  harmless.  It  has 
been  used  by  me  less  and  less  of  late,  save  with  the  severest  cases, 
in  which  I  have  employed  it  for  its  caloric  value,  and  I  have  at  no 
time  prescribed  as  much  as  30  c.c.  every  three  hours.  Martin, 
and  Mason,2  in  their  series  of  cases  used  it  with  only  one  patient. 
One  should  not  prescribe  alcohol  thoughtlessly  for  dial>etics.  They 
may  acquire  the  habit,  though  this  is  far  less  common  than  one 
would  suppose.  For  this  reason  9,">  per  cent,  alcohol  may  be  given 
instead  of  alcoholic  beverages. 

(>.  Liquids.  —  It  is  rarely  necessary  to  restrict  the  liquids  in 
diabetes.  The  diminution  of  the  carbohydrate  in  the  diet  usually 
leads  to  a  corresponding  diminution  in  the  thirst  and  quantity  of 
urine.  I  hesitate  to  restrict  liquids  in  severe  diabetes  for  fear  too 
little  liquid  will  be  available  for  the  body  with  which  to  eliminate 
the  acids  which  may  have  been  formed.  On  the  other  hand,  patients 
often  upset  the  digestion  by  drinking  large  quantities  of  liquids 
rapidly.  This  is  avoided  by  allowing  only  half  a  glass  of  liquid  at 
a  time,  though  the  patient  is  instructed  to  take  that  as  frequently 
as  desired.  Case  Xo.  119(1  continually  voided  large  quantities  of 
urine,  but  usually  I  could  find  a  cause  such  as  the  ingestion  of  20 
or  more  grams  of  salt,  bouillon  cubes  in  variable  number  or  21  half- 
grain  saccharin  tablets  a  day.  Ice-water  should  be  discouraged. 

7.  Sodium  Chloride. — Salt  is  of  great  service  to  the  diabetic  patient. 
If  it  is  withdrawn  from  the  diet  the  weight  falls,  due  to  excretion  of 
water,  and  the  skin  and  tissues  of  the  patient  become  obviously  dry. 

'  Allen  and  DuBois:   Arch.  Int.  Mod.,  1910,  xvii,  p.  1010. 
2  Martin  and  Mason:  Am.  Jour.  Mod.  So.,  1917,  p.  50. 


1)1  KT  L\  HEALTH  A\D  J\  DIABETES 


In  the  early  days  of  the  fasting  treatment  patients  often  lost  much 
weight  because  water  alone  was  allowed.  For  example,  I  learned  of 
one  case  who  lost  1.'!  pounds  in  four  days  in  this  manner.  AVheii 
broths  are  freely  given  during  fasting  it  is  not  uncommon,  par- 
ticularly in  the  presence  of  acidosis,  to  see  a  patient  gain  weight,  and 
invariably  such  patients  feel  better  than  those  who  lose. 

Salt  is  very  freely  used  by  diabetic  patients.  I  do  not  remember 
to  have  ever  seen  a  diabetic  patient  who  took  too  little  salt.  One 
of  my  fasting  cases  was  accustomed  to  shake  it  into  his  hand  to 
eat.  Patients  will  often  salt  their  broths,  although  they  contain 
considerable  salt.  An  analysis  of  the  duplicate  portion  of  the  broth 
which  Case  Xo.  7()5  drank  in  three  days  is  recorded  in  Table  K>7. 

TABLE  137. — BKOTH  TAKKN  BY  CASK  Xo.  7(5")  i\  THREE  DAYS  AT  THE  XKW 
K.\<a,A\n   DKACONESS  HOSPITAL. 

Volume  of  broth  ingested  in  three  <l:iys,  1220  e.c. 


Salt 

Total 
grains. 

10    7 

Per  rent. 
0  SS 

Total  calories 
per  1(C>  c.c. 

0  0 

XitrogiMi 
Fat 

.        .        .         2.:>7 

0.6 

0.21 
0.05 

5.2 
0.5 

The  same  patient  used  20  grams  of  salt  from  the  salt-cellar  during 
the  week  which  included  two  fasting  days  and  five  other  days  upon 
which  she  took  )>()()  grams  washed  vegetables  and  from  !.")()  to  1225 
grams  fish  or  lean  meat.  To  avoid  such  excessive  use  of  salt,  nurses 
arc  advised  to  serve  no  salt  with  broths. 

Case  Xo.  9X2,  a  young  man  with  onset  of  diabetes  at  the  age  of 
twenty,  excreted  40. o  grams  of  sodium  chloride  on  February  1">, 
19 1C),  and  a  few  days  later  the  aliquoted  urine  of  two  days  contained 
XO.C)  grams.  I  p*.n  inquiry  1  learned  from  his  nurse;  that  in  addition 
to  the  ordinary  amount  of  salt  in  the  food  as  it  was  prepared  the 
young  man  filled  a  salt-cellar  each  morning  and  emptied  it  before 
night. 

TABLK   loS. — KKCKSSIVI;   INTAK.I:  OK  SODITM  (  'HLOIUDK   BY  A  DIABETIC- 
HOY. 


Vol.,        Nad.      Dial-otic    Nitrogen.     Pillar, 


Protein.'   Fat, 


ISO 


107     M:{    21 0(.) 
1)7     111    220X 
111)     <)">     111    21">2 


THE  DIET  OF  DIABETIC  INDIVIDUALS  285 

An  oatmeal  cure  is  accompanied  by  the  vise  of  much  salt.  In  the 
preparation  of  the  standard  240  grams  dry  oatmeal  a  cook  would 
employ  about  10  grams  salt.  This  may  be  of  importance  in  the 
explanation  of  the  edema  which  often  accompanies  the  oatmeal  cure. 

\  egetable  foods  are  rich  in  potassium  and,  as  any  farmer's  child 
who  salts  the  cattle  Sunday  mornings  knows,  deficient  in  sodium. 
It  is  not  strange,  with  our  free  use  of  vegetables,  that  diabetic 
patients,  like  cattle,  crave  salt.  But  there  is  still  another  reason, 
because  when  an  excess  of  potassium  is  eaten,  it  is  quickly  dis- 
charged and  along  with  the  potassium  goes  sodium  as  well.  A 
meat  diet  requires  little  salt. 

Attention  may  be  called  to  the  low  excretion  of  salt  in  coma. 
In  a  recent  case  (Xo.  1053)  two  days  before  death  the  quantity  of 
salt  was  1.28  grams,  and  in  the  twenty-four  hours  preceding  death 
amounted  to  but  0.44  gram. 

The  part  played  by  sodium  bicarbonate  in  influencing  the  weight 
indirectly  through  its  action  upon  salt  is  discussed  under  Treat- 
ment of  Acid  Intoxication.  The  salt  metabolism  of  diabetic  patients 
requires  careful  study.  This  should  be  undertaken  in  connection 
with  a  study  of  the  sugar,  fat,  and  salt  in  the  blood  and  the  weight 
of  the  patient,  in  addition  to  the  salt,  sugar,  and  nitrogen  in  the 
urine. 

8.  Lime  Deficiency  in  Diabetes. — Other  anomalies  aside  from  those 
associated  with  sodium  chloride  very  likely  occur  in  diabetes.  Thus 
Max  Kahn  and  Morris  IT.  Kahn1  placed  five  diabetic  patients  of 
mild  character  upon  Folin's  standard  diet  for  nine  days  and  found 
that  they  constantly  lost  calcium.  The  administration  of  calcium 
intravenously  into  diabetic  patients  has  been  reported  to  cause  a 
marked  fall  in  the  excretion  of  glucose  and  a  gradual  decline  in  the 
sugar  in  the  blood. 

The  injection  of  calcium  during  the  height  of  anesthesia  with 
magnesium  quickly  abolishes  this  state  and  in  correspondence  with 
this  antagonism  there  is  a  rapid  return  of  blood-sugar  content  to 
the  normal.2 

I  nderhill3  also  found  that  intravenous  injection  of  sodium  car- 
bonate into  rabbits  might  induce  a  marked  though  transient  fall 
in  the  blood  sugar. 

After  total  pancreatectomy  in  dogs,  Lebensohn4  observed  no 
change  in  the  absorption  of  chlorides  and  no  relation  to  the  XI I3 
excretion. 

1  Kahn  and  Kahn:  Aroh.  Int.  Mod.,  191G,  xviii,  p.  212. 

2  Undcrhill:  Jour.  Biol.  Them.,  July,  1916,  xxv,  p.  471. 
sTJnderhill:   Ibid.,  p.  463. 

4  Lebensohn:  Jour.  Biol.  Chem.,  1915,  xxiii,  Xo.  2,  p.  513. 


SECTION  V. 
TREATMENT. 


A.     PROPHYLAXIS. 

THE  prophylactic  and  etiological  treatment  of  diabetes  will  surely 
play  an  important  role  in  the  future,  and  it  is  already  plain  that 
progress  will  be  along  two  lines:  (1)  toward  the  early  detection 
of  the  disease,  and  (2)  toward  the  prevention  of  the  development 
of  the  disease  in  those  susceptible  to  it.  The  whole  trend  of 
Naunyn's  teaching  favors  the  energetic  treatment  of  the  slightest 
evidence  of  diabetes.  Only  by  following  this  plan  are  regrets 
avoided.  The  importance  of  the  treatment  of  incipient  pulmonary 
tuberculosis  is  not  greater  than  that  of  the  treatment  of  incipient 
diabetes.  The  tendency  to  diabetes  frequently  remains  latent 
for  a  long  time,  and  this  is  well  illustrated  by  the  appearance  of 
diabetes  in  the  children  before  it  occurs  in  the  parent.  In  many 
instances  the  disease  breaks  out  temporarily  before  the  glycosuria 
becomes  permanent.  Case  No.  129  showed  sugar  in  the  urine  in 
1(,)01  at  the  age  of  three  years  "at  a  time  when  she  appeared  out 
of  condition.  Examining  frequently  after  that  I  failed  to  find  it 
and  did  not  look  for  it  again  until  in  February,  1!)05,  when  she 
appeared  like  a  full-fledged  case  of  diabetes."  Death  occurred 
in  coma  in  July,  1007. 

( 'ase  No.  2o")  showed  1 .'.}  per  cent,  of  sugar  in  the  urine  January 
'•>,  11)01,  at  the  age  of  twenty-six  years,  one  month  after  an  attack 
of  severe  catarrhal  jaundice.  The  glycosuria  disappeared  at  once 
on  restriction  of  diet  and  did  not  return  after  resumption  of  a 
liberal  diet  containing  sugar.  December,  1<)01,  right  pyelonephritis, 
urine  sugar-free;  .January  o,  11)0."),  sugar  appeared  with  a  moderate 
amount  of  acetone,  but  no  diacetic  acid,  and  the  patient  became 
sugar-free  with  a  strict  diet  and,  until  July,  !!)()('),  was  able  to  eat 
freely  of  toast,  oatmeal,  potato,  rice  or  oranges  without  glycosuria. 
Death  in  coma  May  1,  HMO.  '\  he  patient  was  under  the  care  of 
Theodore  Janeway  save  for  a  few  days  in  1()0(,),  when  he  underwent 
several  metabolism  experiments  at  the  Nutrition  Laboratory. 

Case  No.  100S  showed  sugar  in  the  urine  on  repeated  occasions 
(280) 


PROPII Y  LAX  IS  287 

at  the  age  of  forty  years,  was  carefully  treated  for  sixty  days  and 
later  no  sugar  was  found,  but  it  reappeared  when  the  patient  was 
fifty-one,  and  he  came  under  my  observation  three  years  later,  with 
severe  diabetes. 

1.  Early  Diagnosis, — The  only  way  in  which  an  early  diagnosis 
of  diabetes  \vill  ever  be  made  is  to  search  for  it.  It  is  possible  that 
tests  of  the  blood  may  soon  give  us  still  earlier  hints  of  the  presence 
of  the  disease,  but  at  present  the  only  practical  method  is  to  make 
frequent  examinations  of  the  twenty-four-hour  quantity  of  urine. 
Bergell1  has  described  a  test  to  determine  a  predisposition  to  diabetes. 
The  urine  is  diluted  to  a  specific  gravity  of  exactly  1012,  but  if 
it  is  more  dilute,  it  is  not  concentrated;  then  7  c.c.  of  a  15  per  cent, 
solution  of  sodium  hydroxide  are  shaken  up  once  with  20  c.c.  of  urine. 
Three  cubic  centimeters  of  a  solution  of  copper  sulphate  (138.78 
grams  CuSO4  to  1000  c.c.  water)  are  added  and  the  whole  vigorously 
shaken  for  ten  seconds.  It  is  then  filtered  through  a  coarse  filter; 
the  first  2  c.c.  are  thrown  away  and  the  fluid  which  filters  through 
in  the  next  six  minutes  is  collected  in  test-tubes  of  uniform  size.  In 
the  healthy  the  fluid  is  only  very  little  discolored,  but  in  the  diabetic 
and  in  those  who  develop  diabetes  later  there  is  a  pronounced  blue 
tint.  He  reports  the  reaction  present  in  80  per  cent,  of  the  children 
of  diabetics.  Randnitz2  failed  to  confirm  these  results. 

The  results  of  life  insurance  examinations  (see  page  1(>7)  show  how 
useful  such  examinations  are,  and  it  is  a  hopeful  sign  that  the 
insurance  companies  are  offering  to  examine  gratis  at  frequent 
intervals  the  urines  of  their  policy  holders.  The  tendency  toward 
more  and  more  frequent  examinations  of  the  urine  goes  steadily 
forward.  It  is  a  good  rule  to  advise  everyone  to  have  the  urine 
examined  upon  his  or  her  birthday,  and  no  physician  should  see 
a  patient  without  examining  the  urine  at  least  every  six  months. 
But  the  responsibility  for  urinary  examinations  rests  not  alone 
upon  the  family  physician.  It  is  the  duty  of  all  specialists  either 
to  examine  the  urines  of  their  patients  or  to  assure  themselves  that 
such  examinations  have  been  recently  made,  and  the  time  is  not 
far  distant  when  this  course  will  be  adopted  by  progressive  dentists 
as  well.  One  of  the  greatest  aids  to  this  policy  has  been  the  establish- 
ment of  laboratories  where  patients  and  physicians  can  secure 
examinations  of  urine  at  trifling  cost.  Such  institutions  have  come 
to  stay. 

2.  Heredity. — The  hereditary  and  familial  tendency  of  diabetes 
has  already  been  discussed.  Fortunately,  many  of  these  cases  are 
mild.  Recognizing  the  hereditary  and  familial  tendency,  relatives 
of  a  diabetic  patient  should  always  be  kept  under  supervision,  and 

1  Bergell:   Deutschc   mod.    Wclmschr.,    1914,    xl,    p.  2094. 

2  Randnitz:   Wiener  klin.  Wchnschr.,  1910,  xxix,  p.  1023. 


2S8  TREATMENT 

urinary  examinations  should  be-  made  at  more  frequent  intervals 
than  in  other  individuals.  Particularly  should  the  urines  of  sueh 
individuals  be  carefully  examined  when  conditions  arise  which 
would  favor  the  development  of  diabetes.  One  should  also  endeavor 
to  prevent  the  outbreak  of  diabetes  by  instructing  such  individuals 
first  to  control  the  total  quantity  of  food  eaten  by  their  body  weight, 
and  second  to  take  carbohydrate  almost  exclusively  in  the  form  of 
starch  rather  than  sugar,  and  never  to  indulge  in  unusual  quantities 
of  carbohydrate,  such  as  candy,  maple  sugar,  or  sweet  fruits.  Third, 
it  would  be  a  great  mistake  to  consider  the  diet  alone  of  importance. 
Mental  relaxation  and  physical  exercise  should  be-  promoted.  Jf 
we  are  to  bring  about  a  decrease  of  diabetes  in  the  community  it 
will  be  with  measures  such  as  these.  Every  agency  which  promotes 
health  and  physical  development  tends  to  prevent  an  outbreak  of 
flic  diabetic  tendency.  "It  is  easier  to  keep  well  than  to  get  well." 
(Greeley.) 

It  would  be  most  unfortunate  for  two  individuals  each  hereditarily 
burdened  with  diabetes  to  wed,  though  by  care  in  environmental 
conditions  the  consequents  of  heredity  might  be  averted  and  the 
tendency  decrease  in  the  third  generation.1 

3.  Obesity. — No    preexistent  abnormal  condition    has  occurred 
more   frequently   among   my   diabetic  patients  than   has   obesity. 
(See  Table  3!).)     Obesity  ail'ords  a   splendid  opportunity  for  the 
physician  in  which  to  practice  preventive  medicine.    The  individual 
who  allows  himself  or  herself  to  become  fat  may  easily  develop 
diabetes.     It  is  desirable  to  spread  the  information  that  those  live 
longest  who  above  the  age  of  thirty-five  years  are  .">  to  10  per  cent, 
below  the  average  normal  weight  and  that  so  little  an  excess  of 
weight  as  ">  per  cent,  is  fraught  with  danger.     Patients  should  be 
cautioned  against  gaining  weight  at  any  period,  but  particularly 
after  infectious  diseases,  pregnancy,  the  climacteric,  and  following 
changes  from  an  active  to  a  sedentary    mode  of  life.     Since  obese 
patients  are  prone  to  diabetes,  they  should  have  frequent  examina- 
tions of  the  urine  made.     Although  emphasis  is  usually  laid  upon 
the   appearance    of    sugar    in    the    urine    with    a    patient    losing 
weight,    it    cannot    be    too   strongly  emphasized  that  it  is  a  com- 
mon occurrence  for  sugar  to  appear  in  the  urine  when   a   patient 
is  gaining  weight. 

4.  Infectious  Diseases. -  The  development  of  diabetes  following 
infections  diseases  i>  a    striking   phenomenon.      Far  less  instances 
have  occurred  in  my  own  experience  than  1  had  anticipated  before  a 
careful  search  of  my  own  cases  was  made.     (See  pp.  112  and  71.) 
Even  during  the  excessive  carbohydrate  feeding  of  typhoid  fever  it 

'  Pril.r.-mi:   /tx-lir.  f.  klin.  Mod..   1014.  Ixxxi.   p.  li'O. 


PROPHYLAXIS  2.S9 

is  said  that  glycosuria  seldom  develops.  Cases  of  diabetes  following 
infectious  disease,  however,  are  so  startling  when  they  do  occur  and 
at  times,  though  by  no  means  always  (see  the  case  of  Schmitz,  p.  4S), 
are  apt  to  be  so  severe  that  the  physician  should  always  examine  the 
urines  of  patients  during  an  infectious  disease,  during  convalescence 
and  without  fail  before  discharging  the  patient.  This  is  doubly 
important  because  a  nephritis  might  be  disclosed  even  though 
diabetes  were  not.  The  usefulness  of  urinary  examinations  will 
become  increasingly  apparent  just  as  soon  as  busy  physicians  get 
the  habit  of  testing  the  urine  for  albumin  and  sugar  in  the  patient's 
home  with  as  little  formality  as  they  make  a  test  of  the  blood- 
pressure. 

5.  Pregnancy. — Sugar  is  apt  to  occur  in  the  urine  during  preg- 
nancy. The  subject  will  be  discussed  more  in  detail  later  on  under 
the  treatment  of  diabetes  in  pregnancy.  It  is  mentioned  here 
simply  to  emphasize  the  point  that  mild  cases  of  glycosuria,  which 
go  untreated  in  pregnancy,  may  later  on  in  the  same  or  in  subse- 
quent pregnancies  become  aggravated  cases  of  diabetes.  It  is 
perhaps  unnecessary  to  absolutely  exclude  the  last  trace  of  sugar 
from  the  urine  in  pregnancy  when  the  sugar  amounts  to  only  0.2 
or  0.3  per  cent,  on  a  diet  which  contains  as  much  as  100  grams  of 
carbohydrate  or  more,  but  it  is  essential  that  the  percentage  of 
sugar  should  be  kept  as  low  as  this,  and  upon  the  first  indication 
of  an  increase  routine  diabetic  treatment  should  be  instituted. 

(>.  Hygiene. — (a)  Physical  Hygiene. — Any  agency  which  promotes 
physical  or  mental  hygiene  is  a  step  toward  the  prevention  of  dia- 
betes in  the  predisposed,  and  the  abatement  of  its  severity  when  it 
has  appeared.  It  should  be  recorded  to  the  creditof  I  )r.  A.  J.  Hodgson1 
that  for  years  in  dealing  with  his  patients  he  has  urged  that  they 
"should  be  kept  mentally  indolent  and  physically  active."  The  ex- 
periments of  Cannon,-  Folin3  and  their  associates  upon  the  appear- 
ance of  sugar  in  the  urine  of  animals  and  of  both  normal  and  insane 
individuals  following  periods  of  great  emotional  excitement  have 
demonstrated  the  truth  of  the  former  half  of  the  motto.  Therefore 
all  individuals  who  have  a  tendency  toward  diabetes  should  be 
especially  urged  to  take  vacations,  and  the  good  effect  of  vacations 
should  be  generally  pointed  out.  I  have  never  forgotten  the  remark 
of  Dr.  Sabine,  of  Brookline,  that  in  the  course  of  his  long  practice 
he  had  observed  that  those  of  his  patients  who  had  taken  active 
camping  trips  in  the  woods  bore  the  stress  of  modern  lite  best.  By 
this  means  exercise  was  combined  with  mental  relaxation.  That  the 
good  effects  of  each  last  for  months  is  not  hard  to  believe.  It  is  only 


19 


200  TREATMENT 

natural  to  conclude  that  if  tin-  muscles,  in  which  is  stored  one-halt' 
of  the  carbohydrate  of  the  body,  are  kept  in  good  condition  by  train- 
ing, a  favorable  effect  must  be  exercised  upon  the  general  metabolism 
of  carbohydrate.  The  man  who,  in  middle  life,  gives  up  hard 
physical  work  and  is  promoted  to  an  oflice  chair  with  increased 
mental  worry  is  exposed  to  diabetes. 

(b)  Mental  Hygiene.-  The  change  in  the  mental  attitude  of 
patients  during  the  course  of  treatment  is  a  gratifying  encourage- 
ment to  the  physician.  Untreated  diabetics  after  a  moderate 
number  of  years  usually  show  mental  depression,  and  with  women 
this  often  becomes  pronounced.  In  the  first  ten  years  of  my 
experience  with  diabetes  I  was  much  impressed  with  the  tendency 
of  such  patients  to  cry,  but  even  then,  with  the  methods  in  vogue, 
it  was  interesting  to  see  how  depression  disappeared  with  the 
decrease  or  disappearance  of  sugar  in  the  urine.  This  could  not 
be  explained  by  the  mental  encouragement  which  a  patient  derived 
from  his  knowledge  of  the  decrease  in  sugar  excretion.  Even  when 
patients  became  free  from  sugar  but  developed  acidosis,  mental 
symptoms  often  improved,  and  to  so  great  an  extent  that  one 
could  say  that  with  treatment,  even  though  it  did  end  in  coma, 
the  patient  enjoyed  life  far  more  thoroughly  than  when  untreated, 
his  life  ended  with  debility  or  tuberculosis.  Might  this  be  asso- 
ciated with  depression  of  the  metabolism  in  the  one  instance  and 
its  stimulation  in  the  other?  During  the  last  two  years  and  a  half 
the  mental  attitude  of  the  patients  has  improved  still  more.  The 
enthusiasm  about  new  methods  of  treatment  has  been  so  great  as 
to  account  partially  for  this,  but  the  actual  improvement  in  health 
which  the  patients  have  felt  has  been  of  more  importance.  (Jreeley 
explained  to  my  patients  how  diabetes  has  largely  been  robbed  of 
its  terrors.  lie  urged  the  simple  life  as  a  great  aid  in  treatment  and 
told  them  not  to  try  to  be  first  in  the  Iberian  village  and  be  ill,  but 
rather  to  be  second  in  Rome  and  keep  well.  He  told  them  to  have  a 
hobby,  and  not  to  make  it  a  labor;  to  be  cheerful  and  to  keep  their 
minds  occupied,  and  as  far  as  possible  to  continue  the  previous 
currents  of  their  lives. 

Heavy  responsibilities  should  be  avoided  as  well  as  nervous 
upsets  and  emotional  excitements.  It  is  almost  as  dangerous  for  a 
diabetic  to  get  angry  as  for  a  man  \vith  angina  pectoris.  Case  No. 
1  lf)7  had  been  sugar-free  for  five  days,  but  it  came  back  when  he  had 
an  important  conference  with  one  of  his  superintendents. 

Allen's  diverting  exercises  have  promoted  the  mental  hygiene 
of  the  diabetic  patient  in  a  most  helpful  manner.  In  Section  II 
the  effect  of  exercise  upon  diabetic  patients  has  been  discussed  at 
length.  Stimulated  by  Dr.  Allen,  I  have  gradually  increased  the 
exercise  of  all  my  patients,  except  those  unduly  weak  or  in  a  dan- 


PROPHYLAXIS  291 

gerous  condition  upon  entrance  to  the  hospital.  The  effect  of  this 
increase  of  exercise  upon  the  well-being  of  fat  diabetics  has  been 
pronounced,  and  it  is  striking  how  many  miles  a  semi-ill  or  an  obese 
diabetic  patient  can  learn  to  walk  during  t\vo  weeks.  The  patients 
are  encouraged  to  take  their  walks  soon  after  meals  and  to  go  out- 
doors at  least  five  times  in  the  day.  Not  alone  are  the  good  effects 
of  exercise  shown  by  freedom  of  the  urine  from  sugar  with  an 
increased  carbohydrate  tolerance,  but  by  improved  circulation  and 
general  well-being.  Even  fasting  diabetics,  as  a  rule,  appear  to  do 
better  when  up  and  about  the  wards  for  a  few  hours  a  da}'  than 
when  abed.  However,  caution  is  necessary  in  suggesting  this  plan 
to  severe  cases  of  diabetes.  It  must  be  remembered  that  Case  No. 
304  went  into  coma  following  a  period  of  active  exercise  in  the 
year  1910,  although  the  diet  had  been  only  moderately  restricted; 
yet  it  should  be  said  that  she  was  a  case  of  nine  years'  duration,  and 
any  lowering  of  the  carbohydrates  without  a  corresponding  decrease 
in  fat  in  such  a  patient  is  apt  to  prove  serious.  It  is  yet  too  early 
to  say  whether  we  shall  be  able  to  change  "the  emaciated,  soft- 
muscled  diabetic  into  an  athlete,"  but  there  is  no  question  but 
that  it  is  worth  while  to  try  to  do  so.  Xo  case  should  be  considered 
too  far  advanced  for  an  attempt  at  muscular  redevelopment.  I  have 
seen  two  patients,  so  weak  from  inanition  that  they  could  not  stand, 
through  .the  help  of  skilful  massage  and  carefully  planned  dietetic 
treatment  again  begin  to  walk.  By  exercise,  as  Allen  points  out, 
fat  must  be  reduced  and  muscle  tissues  built  up.  I  can  agree  with 
Dr.  Allen  that  "it  is  hoped  that  an  end  may  be  put  to  the  period 
of  the  pale,  feeble  diabetic,  dressed  in  double  underwear,  hugging 
the  radiator,  and  growing  more  neurasthenic  all  the  time."  I  must 
acknowledge  that  I  have  not  yet  been  able  to  wean  my  patients  from 
the  radiator,  but  I  expect  to  be  able  to  do  so  by  means  of  exercise 
and  more  food. 

Exercise  must  not  be  carelessly  undertaken.  Graham1  demon- 
strated that  whereas  the  blood  sugar  after  a  meal  of  100  grains 
glucose  attains  its  maximum  in  twenty  minutes  and  returns  to 
normal  in  an  hour  to  an  hour  and  a  half,  under  conditions  which 
cause  fatigue  the  blood  sugar  rises  to  a  greater  height  and  takes 
three  or  four  hours  to  fall  to  its  original  level.  Cannon2  also  observed 
an  increase  of  sugar  in  the  blood  during  fatigue  but  considered  this  a 
result  of  design  on  the  part  of  the  body's  protective  mechanism. 

If  the  patient,  by  means  of  exercise,  can  have  5  grams  more  of 
carbohydrate  a  day  the  added  comfort  will  be  enormous,  for 
the  addition  of  5  grams  of  carbohydrate  to  a  diet  in  a  case  of 
severe  diabetes  brings  almost  untold  joy.  It  allows  various  alter- 


i:  Jour.  Physiol.,  1916,  1,  p.  285. 
2  Cannon;  Am,   Jour.  Phy^iol.,    1914,   xxxiii,    p.  372. 


292  TREATMENT 

natives — half  a  small  orange,  .">()  grains  of  strawberries,  a  small 
tablespoonful  of  cooked  oatmeal,  or  a  potato  half  the  si/e  of  a 
pullet's  egg. 

Finally,  it  is  astonishing  ho\v  much  exercise  a  diabetic  in  training 
can  take.  One  of  my  severe  cases  living  on  a  strict  diet  several  years 
ago  walked  between  twenty  and  thirty  miles  in  one  day.  Inquiry 
elicited  the  following  letter  from  Case  No.  7SM,  a  Harvard  student, 
\vlio  frequently  shows  a  small  trace  of  sugar  which  borders  upon  the 
renal  type  of  diabetes.  The  blood  sugar  one  morning  before  break- 
fast was  0.07  per  cent.: 

CAMHUID<;K,  MASS.,  Doci'mber  1,  1015. 

"MY  DKAK  DOCTOR  JOSLIX:  1  first  noticed  the  eil'ect  of  exercise 
last  spring.  I  was  rowing  for  exercise  at  the  time,  and  observed 
that  if  I  went  out  on  the  river  about  half  an  hour  after  lunch  and 
rowed  for  an  hour  or  less,  the  test  would  not  show  any  sugar  in  the 
urine  at  any  time  during  the  afternoon,  even  though  1  ate  potatoes 
and  a  small  amount  of  bread  for  lunch.  But  if  I  ate  any  potatoes 
(no  bread)  without  so  exercising,  the  test  always  showed  sugar 
about  two  hours  after  the  meal." 

7.  Syphilis. — The  type  of  diabetes  which  occurs  in  syphilis  is 
usually  mild.  Apparently  the  disease  is  not  very  closely  related 
to  diabetes,  but  all  statistics  must  stand  in  abeyance  until  the 
results  of  modern  tests  for  the  detection  and  treatment  of  syphilis 
are  known.  Approximately  2  per  cent,  of  my  own  cases  of  diabetes 
surely  had  syphilis.  In  the  first  400  cases  the  disease  was  recognized 
six  times,  in  the  second  400  cases  seven  times  and  in  the  third  400 
cases  there  were  six  instances.  At  the  Peter  Bent  Brigham  Hospital 
the  proportion  of  syphilis  (positive  YYassermaini  tests)  among  dia- 
betics was  found  to  be  S  per  cent,  among  SO  diabetics  by  \\alker 
and  Ilaller,'  but  this  was  only  about  half  the  incidence  of  syphilis 
among  4000  of  the  general  hospital  population.  These  figures  arc* 
in  sharp  contrast  to  the  surprising  figures  of  \\arthin  and  \Yilsoir 
for  Michigan.  They  record  that  in  six  autopsies  performed  at  the 
1  diversity  of  Michigan  upon  diabetics  since  HK)7  histological 
changes  of  syphilis  were  present  in  all  and  in  four  spirochetes  were 
demonstrated  in  the  myocardium  and  in  one  of  these-  cases  also 
in  the1  pancreatic  lesions.  As  evidence  of  the  connection  between 
diabetes  and  syphilis  these  authors  examined  the  pancreas  in  a 
series  of  Mi)  cases  of  old  latent  syphilis  and  found  it  abnormal  in  all. 
I  make-  no  effort  to  explain  the-  discrepancy  between  tin-  Massa- 
chusetts and  Michigan  figures. 

Barach'1  among  Ml   diabetics  seen  within  two  and  a  half  years, 

1  Walker  and   Hallcr:   .lour.   Am.   Mr,!.  Assn.,    lOKi,   Ixll,   p.  4SS. 
-  Wurthin  ami  WiNon:   Am.  .lour.  Mrd.  Sc.,    HMD,  clii,  p.   157. 
3  Burach:   Boston  Mod.  and  Surn.  Jour.,  1017,  rlxxvi,  p.  58. 


PROPHYLAXIS  293 

believes  there  were  primarily  3  cases  of  syphilis  and  he  notes  that 
another  had  a  positive  Wassermann  reaction,  another  was  the  hus- 
band of  a  syphilitic  and  another  the  husband  of  a  paretic. 

Several  of  the  cases  with  a  syphilitic  history  have  been  of  long 
duration.  This  type  of  the  disease  has  occurred  so  frequently  in 
connection  with  known  syphilis  that  one  must  suspect  the  presence  of 
syphilis  in  mild  diabetes.  (See Table  139.)  In  illustration  of  the 
above  1  would  cite  the  following  case:  Case  Xo.  503  acquired  syphilis 
at  the  age  of  sixteen  years,  and  was  energetically  treated  by  the 
older  methods.  Fourteen  years  later,  in  May,  1912,  when  about 
to  undergo  an  operation  for  appendicitis,  sugar  was  found  at  a 
routine  examination,  and  the  Wassermann  reaction,  which  had  not 
previously  been  tried,  was  demonstrated  to  be  positive.  lie  was 
given  a  thorough  course  of  treatment  with  salvarsan,  and  the 
Wassermann  reaction  has  remained  negative.  Under  dietetic  treat- 
ment sugar  decreased  and  gradually  a  marked  carbohydrate  toler- 
ance was  acquired.  Xo  further  antisyphilitic  treatment  has  been 
given.  On  August  19,  1915,  the  urine  contained  0.5  per  cent,  of 
sugar  and  the  carbohydrates  in  the  diet  amounted  to  140  grams. 
The  blood  sugar  amounted  to  0.1  (>  per  cent,  fasting.1  On  March 
8,  1917,  the  urine  was  sugar-free  and  the  high  tolerance  persisted. 

It  would  seem  as  if  syphilitic  diabetes  was  an  ideal  object  for 
etiological  treatment,  but  all  writers  agree  that  this  is  not  usually 
the  case.  It  is  true  that  occasionally  a  case  has  been  strikingly 
helped.  For  instance,  Umber2  recorded  a  case  of  diabetes,  male, 
aged  forty-eight  years,  with  syphilitic  infection  in  1S9S.  During 
1909  indigestion,  pain  in  epigastrium,  thirst,  transitory  jaundice, 
loss  of  18  pounds,  and  gastric  tumor  occurred.  Upon  a  diet  of  147 
grams  of  carbohydrate,  113.4  grams  of  sugar  were  eliminated. 
Fatty  stools,  blood  sugar  0.4:5  per  cent.,  Wassermann  reaction 
positive.  Following  the  use  of  0.4  gram  of  salvarsan  the  tumor 
decreased  in  si/e  and  the  stools  became  less  fatty.  There  was  a 
continuous  gain  in  weight  for  one  year,  and  at  the  time  of  recording 
the  case  the  patient  lived  without  restriction  of  carbohydrate  and 
no  tumor  was  to  be  felt.  Hevillet:s  reports  a  cure  with  mercury. 

Walker  and  llaller  report  that  energetic  treatment  of  one  case  of 
diabetes  developing  six  months  after  the  initial  lesion  was  without 
any  influence  on  the  diabetes.  The  blood  Wassermann  became 
much  weaker,  but  never  negative  and  the  patient  finally  died  in 
coma. 

X"o  such  similar  case  has  come  under  my  personal  observation, 
but  I  strongly  feel  that  one  should  constantly  be  on  the  watch  for 
syphilis  in  diabetes,  and  whenever  it  is  present  should  treat  it  by 

1  See  Table  113.  -  Umber:  Mlmchen.  med.  \Vchnschr.,  1911,  Iviii,  p.  2499. 

3  Revillet:  Lyon  Med.,  191G,  cxxv,  p.  374. 


294 


TREATMENT 


modern  methods.  Sufficient  time  has  not  yet  elapsed  since  the 
better  treatment  of  syphilis  has  been  introduced  to  warrant  copying 
the  statement  so  <often  made  by  older  writers  that  antisyphilitic 
treatment  is  of  no  avail  in  diabetes.  Even  if  it  should  not  prove 
of  avail  when  the  disease  is  established,  it  should  be  helpful  in 
preventing  the  onset  of  syphilitic  diabetes. 

The  Wassermann  reaction  has  been  performed  upon  107  of  my 
cases,  and  has  been  positive  in  six  instances.  The  cases  selected 
for  these  Wassermann  tests  were  not  consecutive  cases,  but  chosen 
from  some  .")()()  cases  of  diabetes  because  of  suggestive  history  or 
physical  signs.  The  course  of  the  disease  in  the  10  cases  with  a 
positive  history  of  syphilis  and  in  three  other  individuals  in  which 
it  was  demonstrated  by  a  positive  Wassermann  is  shown  in  Table  139. 

TABLE    DiO. — DURATION*    OF    DIABETES   IN    PATIENTS    SHOWING    A    POSITIVE 
WASSEKMANN  REACTION  OR  PRESENTING  A  POSITIVE  HISTORY  OF  SYPHILIS. 


LIVING  CASES. 

Case  Xo. 

A  ftp  at 
Syphilis. 

onset. 
Diabetes. 

Duration  of 
diabetes  to 
Dec.  1,  1910, 
years. 

IV    .      . 

.       .      20 

40 

0.9 

VI    .      . 
VIII 

.      .      10 
38 

30 
47 
44 

5.1 
4.9 
4.3 

IX    .      . 

.      .      28 

X    .      . 

51 

3.S 

XII    .      . 

40 

1.8 

XIV    .      . 

.      Under  42 

42 

13.1 

XVI    .      . 

.       .      31 

:52 

22.0 

XVII    .      . 
XVIII 

.     .    :u 

44 
54 

5S 

1.6 
1.0 
6.0 

XIX   . 

27 

Average  age  (8  cases)     29 


Case  Xo. 

I  . 

II  . 

Ill  . 

VII  . 

XI  . 

XIII  . 

XV  . 

V  . 


44 

FATAL  CASES. 

.t  onset.                   ( 
Diabetes. 

Duration 
;f  diabetes, 
years. 

42 

10.6 

54 

19.0 

54 

14.0 

41 

1.6 

38 

1.1 

39 

1.0 

54 

7.8 

42 

Cause  of  death, 
eiimonia. 


P 


not  (race. 


48 


According  to  Walker  and  Ilaller1  the  Wassermann  reaction  is 
uninfluenced  by  the  amount  of  sugar  in  the  blood  or  urine  or  by  the 
presence  or  absence  of  coma. 

S.  Pancreatic  Preparations. — The  use  of  thyroid  extract  in 
myxedema  naturally  raised  hopes  that  the  extract  of  the  pan- 

'  Walker  and  Ilaller:  Loc.  eit.,  p.  292. 


PROPHYLAXIS  295 

creatic  gland  would  be  of  avail  in  diabetes.  Up  to  the  present 
time  such  has  not  been  the  case.  An  instance  of  apparent  benefit 
has  been  widely  copied  in  the  literature,  but  the  family  physician 
of  the  patient  assured  me  that  this  alleged  benefit  rested  on  insuffi- 
cient foundation.  Occasionally  a  case  of  diabetes  with  the  external 
symptoms  of  pancreatic  disease,  such  as  fatty  stools,  has  been 
helped  by  the  use  of  preparations  of  the  pancreas,  and  in  such  cases 
the  fresh  gland  has  been  the  most  effective.  Various  pancreatic 
preparations  are  placed  upon  the  market  and  advertised  as  of  great 
value  in  the  treatment  of  diabetes.  I  do  not  use  them. 

9.  Surgery. — Several  cases  of  diabetes  associated  with  gall-stones 
have  done  remarkably  well  when  the  inflammation  about  the  gall- 
stones has  subsided.  They  suggest  that  surgical  intervention  might 
be  advantageously  employed  in  selected  cases.  Case  No.  18,  age 
at  onset  of  diabetes  thirty-five  years,  first  seen  by  me  in  August, 
1900,  at  the  age  of  thirty-nine  years,  has  shown  no  symptoms  of 
diabetes  for  years;  previously  she  had  symptoms  of  gall-stones. 
These  symptoms  have  nowr  disappeared,  though  the  .r-ray  demon- 
strates the  presence  of  calculi.  Case  No.  309  went  through  a  period 
of  involuntary  fasting  and  loss  of  weight  because  of  digestive 
symptoms,  sugar  disappeared,  tolerance  trebled  and  .r-ray  shows 
gall-stones.  Dr.  Allen  has  quoted  a  whole  series  of  interesting  cases 
relating  to  diseases  of  the  pancreas  and  liver  in  which  sugar  disap- 
peared. 

The  favorable  course  of  diabetes  in  the  presence  of  gall-stones  is 
shown  in  Table  140. 

TABLE  140. — DIABETES  ix  ASSOCIATION  WITH  GALL-STONES. 

Duration  of  diabetes. 


Case 
No. 
18   .... 
177 

Age  at 
diagnosis  of 
gall-stones. 
? 

.      25 

Age  at 
onset  of 
diabetes. 
35 
40 

Living 
Dee.  1,  1916, 
years. 
19  .  83 
10.08 

Fatal, 
years. 

200   .      .      .      . 

273 

.      .      .      .      54 

50 

01 
50 

5.00 

8.75 

309   .      .      .      . 

.      .      .      .      20 

35 

20  .  33 

310   .      .      .      . 

.      .      .      .      21 

17 

21.00 

422   .      .      .      . 
457 

.      .      .      .      45 
43 

52 
55 

0  .  50 
0.92 

4G9   .      .      .      . 

.      .      .      .      52 

55 

1.17 

488   .... 

.      .      .      .      40 

59 

5.07 

5GO   .... 

.      .      .      .     40 

00 

5.17 

508   .... 

.      .      .      .      48 

57 

Untraced 

039   .... 

55 

55 

1  .  75 

097   .... 

.      .      .      .      54 

49 

9  .  33 

727   .      .      .      . 

.      .      .      .      52 

52 

7.00 

799    .      .      .      . 

845 

.      .      .      .      35 

57 

44 
59 

3  .  50 
2.50 

954   .... 

? 

50 

1  .  00 

981    .... 

.      .      .      .    27.0 

28 

1.42 

1002  .... 

.      .      .      .      43 

43 

25  ± 

Average  age  (18  cases)  43  49 


2!  Mi  TREATMENT 

The  brilliant  result  of  Cannon,1  in  experimentally  producing 
exophthalmic  goitre  by  suturing  the  sympathetic  to  the  phrenic 
nerve,  suggests  that  some  such  similar  procedure  might  be  employed 
in  diabetes  to  stimulate  the  activity  of  the  pancreas  and  improve 
its  function.  If  we  grant  that  the  pancreatic  gland  is  more'  inti- 
mately associated  with  diabetes  than  any  other  organ  of  the  body, 
we  must  also  grant  that  the  condition  of  the  gland  at  autopsies  in 
the  majority  of  cases  of  diabetes  indicates  that  it  has  not  been 
destroyed,  and  consequently  invites  stimulation  by  surgical  inter- 
vention or  otherwise.  Surgery  may  be  helpful  in  the  treatment 
in  various  other  ways.  The  association  of  glycosuria  with  enlarge- 
ment of  the  thyroid  is  also  a  tempting  field  for  surgical  interven- 
tion, but  so  far  as  I  am  aware  such  cases  have  not  been  operated 
upon  with  this  in  mind.  The  removal  of  a  brain  tumor  may 
cause  the  cessation  of  sugar  in  the  urine.  The  surgery  of  the 
hypophysis  opens  up  new  fields  for  the  treatment  of  a  very  small 
group  of  cases.  Already  Gushing2  has  reported  the  cure  of  diabetes 
insipidus  by  removal  of  the  posterior  part  of  the  gland, ;i  but  so 
far  as  1  am  aware  the  cure  of  a  case  of  diabetes  mellitus  lias  not 
yet  been  accomplished.  The  removal  of  a  fibroid  tumor  of  the 
uterus  is  recorded  here  and  there  in  the  literature  as  resulting  in  the 
cure  (?)  of  diabetes.  Such  a  case  (No.  127)  I  saw  with  the  late 
Dr.  M.  II.  Richardson  in  M/Oil.  The  onset  of  the  diabetes  occurred 
at  the  age  of  thirty-seven  years  in  1S9S,  at  which  time  dieting  was 
begun,  and  the  sugar  disappeared  for  four  years.  Following  the 
operation  there  was  marked  suppuration,  and  it  was  necessary  to 
drain  the  wound  abdominally  and  by  the  perineum.  Convalescence 
finally  took  place.  In  April,  HM)(>,  no  sugar  was  found  upon  two 
examinations,  and  on  May  27,  1(.)12,  sugar  was  absent  from  the 
urine.  This  case  was  lost  sight  of  for  several  years,  but  finally  dis- 
covered by  my  secretary,  Miss  Y\ood,  to  be  alive  on  January  4, 
101C),  but  on  April  2.">,  IDIO,  the  urine-  was  obtained  and  showed 
f>.2  per  cent,  sugar  and  no  diacetic  acid.  The  patient  remains  in  quite 
good  condition  and  on  May  2">,  11)17,  the  blood  sugar  was  0.22  per 
cent,  and  the  urine  showed  0.7  per  cent,  sugar  and  no  diacetic  acid. 

A  similar  case,  reported  by  Miller1,  has  also  been  traced  by  him 
and  he  has  kindly  allowed  UK-  co  report  upon  it.  The1  urine  remained 
sugar-free  for  two  or  three1  months  after  the  operation,  but  later 
malignancy  developed  in  the1  pelvis,  sugar  returned  and  ee)ntinue>d 
until  death. 

The  ivmoval  of  the-  prostate  has  also  led  to  the  disappearance  of 


CLASSIFICATION  297 

diabetes.  Xo  case  of  this  sort  has  come  under  my  personal  super- 
vision and  my  experience  with  diabetes  in  association  with  enlarged 
prostate  has  been  extensive,  through  the  courtesy  of  Arthur  L.  Chute. 

B.     CLASSIFICATION. 

1.  Classification  for  Treatment. — A  classification  of  diabetic 
cases  based  upon  the  assimilation  of  carbohydrate  will  always  be 
found  helpful  in  their  treatment.  It  is  customary  to  divide  cases 
of  diabetes  into  three  types:  mild,  moderately  severe,  and  severe. 
Such  a  classification,  however,  can  never  be  arbitrary,  because 
easels  which  at  first  appear  to  belong  to  the  severest  type  of  the 
disease  may  run  a  favorable  course  and  cases  showing  at  the  outset 
only  a  small  quantity  of  sugar  may  prove  to  be  quite  intractable. 
For  this  reason  Xaunyn  did  not  pretend  to  be  able  to  distinguish 
accurately  between  the  various  types.  Furthermore,  up  to  the 
present  time  it  has  nearly  always  been  considered  that  diabetes 
was  a  progressive  disease,  and  that  each  patient,  if  he  lived  long 
enough,  was  destined  to  pass  through  the  three  stages.  Time 
alone  will  decide  whether  this  unfortunate  conception  of  the  malady 
may  be  given  up.  In  illustration  of  the  above,  Case  Xo.  344 
belonged  to  the  type  of  mild  diabetes  for  nearly  four  years,  but 
gradually  the  character  of  the  disease  changed,  and  ultimately 
reached  its  greatest  severity  in  this  patient;  tuberculosis  then 
intervened,  acidosis  disappeared,  and  he  died,  four  years  after  the 
onset,  of  tuberculosis  rather  than  of  coma.  Case  Xo.  S  responded 
so  well  to  treatment  as  to  justify  being  classed  as  mild  in  type, 
and  even  at  the  end  of  fourteen  years  was  only  moderately  severe, 
death  ensuing  without  acidosis  but  as  a  result  of  arteriosclerotic 
complications.  Case  Xo.  552  appeared  to  belong  to  the  severe 
type  of  diabetes,  but  after  prolonged  treatment  improved  so  much 
as  to  reach  the  border-line  of  the  moderately  severe  group.  Diabetes 
in  children  is  usually  looked  upon  as  severe,  but  a  distinct  fraction 
of  these  cases  prove  to  be  mild  and  the  severity  at  first  observed 
can  be  proven  to  have  been  due  to  the  hand  of  man  and  not  intrinsic 
in  the  disease.  I  believe  few  cases  of  diabetes  are  progressive  in 
character.  (See  Diabetes  of  Fifteen  or  More  Years'  Duration, 
p.  4()S).  Usually  by  "severe"  diabetes  is  understood  those  cases 
where,  to  quote  von  Xoorden,  "notwithstanding  a  prolonged  rigid 
carbohydrate-free  diet  the  urine  contains  sugar."  While  this 
definition  is  open  to  various  criticisms,  it  is  most  useful.  By  a  diet 
as  free  from  carbohydrate  as  possible,  I  think  that  von  Xoorden 
often  means  one  which  contains  vegetables  with  5  per  cent,  carbo- 
hydrate or  less;  in  other  words,  a  diet  with  about  10  grams  carbo- 
hydrate. It  should  be  emphasized  that  cases  of  diabetes  of  long 


29S  TREATMENT 

duration  are  frequently  seen  who,  though  upon  an  almost  carbo- 
hydrate-free diet  for  a  prolonged  period,  continue  to  excrete  in  the 
urine  a  very  small  percentage  of  the  carbohydrate  eaten;  this 
persists  for  weeks,  but  finally  disappears,  yet  at  no  time  could  such 
a  patient  be  classed  as  severe.  Such  a  case  was  No.  1220. 

The  introduction  of  prolonged  and  intermittent  fasting  simplifies 
yet  complicates  the  whole  question  of  classification,  because  prac- 
tically all  patients  can  be  made  sugar-free.  This  would  banish 
the  term  "severe  diabetes"  from  the  category,  and  this  is  undesir- 
able at  the  present  time.  Therefore  classification  in  this  section  on 
treatment  will  be  based  upon  the  supposition  that  severe  cases  of 
diabetes  have  a  tolerance  from  0  to  10  grams  carbohydrate,  moder- 
ately severe  cases  have  a  tolerance  from  10  to  .10  grams  of  carbo- 
hydrate, and  that  the  remaining  cases  are  mild.  This  is  a  cheerful 
and  deserved  tribute  to  Dr.  Allen.  It  is  one  of  the  best  proofs  of  the 
improvement  in  the  treatment  of  diabetes,  but  it  makes  imprac- 
ticable any  satisfactory  classification  of  all  my  earlier  cases.  Of 
the  last  100  cases  seen,  writing  one  year  ago,  12  might  be  con- 
sidered as  severe  cases,  .12  moderate  and  the  remaining  •>(>  cases 
mild,  but  if  1  take  the  last  100  cases  prior  to  March  1,  1<)17,  the 
statistics  are  S  severe,  47  moderately  severe,  and  4-1  mild.  It 
should  be  recognised  that  even  the  severe  cases  might  be  so 
prepared  by  prolonged  fasting  for  a  test  of  their  carbohydrate 
tolerance  as  to  appear  mild.  A  tolerance  obtained  under  such 
conditions  would  b;^  apparent,  not  real. 

The  presence,  absence  or  intensity  of  acidosis  affords  an  unsatis- 
factory basis  for  classification.  Even  the  mildest  case  of  diabetes 
by  restriction  of  carbohydrate  and  increase  in  the  amount  of  fat 
can  be  made  to  develop  an  acidosis  which  will  be  mild,  moderate, 
or  severe  in  degree. 

The  Lusk  dextrose-nitrogen  ratio  is  another  method  of  classi- 
fication. Lusk  groups  cases  as  severe  which,  when  put  upon  a 
protein-fat  diet,  have  a  dextrose-nitrogen  ratio  (1):.\)  of  .">.(>.")  to  1. 
Today  he  recognizes  this  test  as  unsatisfactory  because  of  the  dangers 
which  lurk  behind  such  a  diet,  but  the  introduction  of  fasting  has 
given  a  sate  basis  for  the  determination  of  this  ratio  as  Lusk  and 
Janney  have  emphasized.  The  usefulness  and  reliability  of  this 
ratio  are  unquestioned  when  fasting  lasts  several  days  and  constant 
conditions  as  to  intake  of  liquids  and  salts  are  maintained  and 
alkalis  are  omitted.  Hut  with  my  present  way  of  thinking,  I  should 
consider  it  a  matter  for  self-reproach  to  allow  one  of  my  cases  to 
reach  a  stage  that  he  is  able  to  void  a  urine  with  a  D:X  ratio  of 
.">.('>.")  to  1.  This  very  fact  demonstrates  the  utility  of  this  method 
of  classification  and  its  impracticability  as  well.  \Vriting  in  April, 
1017,  it  now  appears  that  no  such  case  of  complete  diabetes  has 


DIETETIC   TREATMENT  299 

ever  been  reported  if  the  criteria  above  mentioned  for  such  a  test 
have  been  followed.  Unfortunately,  this  test  is  unserviceable  for 
the  general  practitioner,  because  the  facilities  for  determining  the 
nitrogen  in  the  urine  are  not  at  hand.  Usually  the  dextrose- 
nitrogen  ratio  vanishes  with  fasting  save  in  the  few  rare  cases 
with  complications.  Clinicians  should  not  expose  patients  to  a 
protein-fat  diet  simply  to  determine  their  severity.  Case  Xo.  51.'!, 
already  referred  to,  excreted  while  fasting,  a  few  days  preceding 
coma,  suffering  at  the  time  from  a  septicemia,  35. 3  grams  of 
nitrogen  and  112  grams  of  dextrose,  showing  a  dextrose  nitrogen 
ratio  of  3.17  :  1;  the  ratios  were  higher  when  he  was  upon  a  fat- 
protein  diet. 

The  respiratory  quotient  of  a  series  of  cases  of  diabetes  was  found 
by  Benedict  and  myself  to  be  0.73  or  less,  and  the  respiratory 
quotient  of  a  series  of  milder  cases  to  be  above  this  figure.  But  the 
respiratory  quotient  depends  in  such  large  measure  on  the  diet  as 
to  render  it  an  undesirable  method  by  which  to  differentiate  cases 
of  diabetes  even  if  it  were  practicable.  Then,  too,  the  rise  in  the 
quotient  which  has  been  observed  with  fasting  diabetics  confuses 
the  picture. 

2.  Classification  for  Prognosis. — It  is  still  more  difficult  to  classify 
cases  of  diabetes  for  prognosis.  The  past  is  not  a  guide.  Hitherto 
a  case  of  diabetes  occurring  in  an  individual  under  the  age  of  thirty 
years  would  usually  be  set  down  as  severe,  even  though  he  readily 
became  sugar-free;  exceptions  occurred  now  and  then  when  the 
quantity  of  sugar  was  a  mere  trace  and  the  patient  obese.  Cases 
often  appear  severe  when  first  seen,  but  upon  further  acquaintance 
it  is  found  that  this  is  due  to  some  a  lie  viable  circumstance,  such  as 
the  presence  of  an  infection,  or,  more  commonly,  the  sudden  institu- 
tion of  a  fat-protein  diet  with  its  attendant  acidosis. 

The  presence  of  obesity,  a  favorable  heredity,  an  early  diagnosis, 
or  the  history  of  benign  diabetes  of  several  years'  duration  with 
gain  rather  than  loss  in  tolerance,  the  retention  of  body  weight, 
are  good  prognostic  signs,  but  a  placid,  cheerful,  brave  and  honest 
disposition,  inherent  or  acquired,  is  fully  as  important. 

C.     DIETETIC  TREATMENT. 

1.  General  Discussion. — The  treatment  of  diabetes  is  so  largely 
dietetic  that  it  is  especially  important  at  the  start  to  take  a  com- 
prehensive view  of  each  case.  Unless  this  is  done  before  treatment 
is  commenced,  the  attention  of  the  physician  may  be  so  engrossed 
with  the  diet  that  he  falls  into  schematic  ways  and  overlooks  other 
salient  aspects  relating  to  his  patient.  The  etiology  of  the  disease 
in  each  instance  should  be  carefullv  investigated  and  faultv  habits 


300  TUP:  AT  ME  XT 

corrected.  It  will  often  be  found  that  the  symptoms  which  annoy 
the  patient,  bear  little  relation  to  diabetes,  and  these  should  be 
appropriately  treated.  This  is  particularly  true  in  the  diabetes 
of  middle  life  and  old  age,  and  also  with  the  varieties  of  diabetes 
which  are  the  accompaniment  of  the  diseases  of  the  various  organs 
of  the  body.  Tins  broad  view  of  the  case  should  be  maintained 
throughout  the  course  of  treatment,  and  whenever  unsatisfactory 
results  anv  obtained  the  whole  situation  should  be  investigated 
anew  to  determine  whether  some  radical  change  in  the  plan  of 
treatment  should  be  adopted.  A  surgeon  often  overlooks  grave 
medical  complications  in  his  cases  simply  because  his  attention 
is  absorbed  by  the  surgical  aspect  of  his  patient.  More'  than  once 
1  have  discovered  in  my  own  practice,  as  well  as  in  that  of  others, 
the  existence  of  advanced  tuberculosis  which  had  previously 
escaped  attention. 

Patients  with  diabetes  often  come  to  the  physician  in  a  state 
which  is  endurable.  It  is  the  function  of  the  physician  to  improve 
upon  this  state-.  Only  too  frequently  treatment  in  the  past  has 
done  the  patient  more  harm  than  good,  but  the  fault  lies  not  in 
the  principles  of  treatment,  but  rather  in  their  application.  The 
physician  who  undertakes  to  treat  the  patient  with  diabetes  whose 
condition  is  comfortable  resembles  the  surgeon  who,  operating  for 
an  interval  appendix,  assumes  a  responsibility  far  greater  than  when 
acute  symptoms  make-  such  an  operation  imperative. 

In  illustration  of  this  point  1  would  cite  the  following  instance: 

Case  No.  47i>,  aged  forty-eight  years,  buried  a  child  of  diabetes 
at  the  age  of  fifteen  years.  During  November,  1011,  she  began  to 
lose  weight,  and  though  two  quarts  of  urine  were  voided,  no  sugar 
was  found  in  t\vo  inornuifj  specimens  of  urine  either  early  in 
November  or  December.  On  December  ">,  1011,  a  little  sugar  was 
discovered.  January  ~1\,  101L',  she  consulted  a  "specialist."  The 
quantity  of  urine  was  then  six  quarts,  the  percentage  of  sugar  7, 
making  the  total  quantity  of  sugar  for  the  day  nearly  a  pound. 
It  was  reported  to  me  that  she  said  that  if  she  had  diabetes  "  she 
would  not  do  a  thing  for  it."  The  "specialist"  radically  restricted 
/lie  carbohydrnlc  in  tin1  il/cf,  and  three  days  later,  in  consultation 
\vitli  her  family  physician,  I  found  her  in  coma.  This  is  one  of  the 
cases  which  led  me  to  consider  the  first  year  following  the  detection 
of  the  disease  to  be  the  diabetic's  danger  /.one.  It  is  one  of  the  cases 
which  formerly  would  have  gone  down  in  the  literature  as  "acute 
diabetes." 

The  responsibility  for  the  management  of  the  diet  of  a  diabetic 
patient  should  always  rest  upon  one  individual.  As  a  rule  that 
individual  is  the  patient,  but  at  times  another  member  of  the  house- 
hold. Children  who  are  above  the  age  of  ten  vears  should  be  taught 


DIETETIC    THE  ATM  EXT  301 

to  plan  their  own  diet.  They  readily  learn  to  do  this  and  in  so  doing 
make  their  elders  blush.  In  fact  it  is  more  important  for  diabetic 
children  to  learn  what  and  how  much  to  eat  than  all  the  knowledge 
which  their  schools  ail'ord,  for  upon  this  information  their  life 
depends.  Perhaps  it  is  because  this  personal  responsibility  is  so 
deeply  felt  in  the  management  of  little  children  that  the  treatment 
of  diabetes  in  them  proceeds  so  uniformly  and  always  produces 
results  so  much  better  than  are  expected.  Conversely,  the  failure 
of  diabetic  patients  to  do  well  in  the  open  wards  of  large  hospitals 
has  been  due  not  so  much  to  the  alleged  dishonesty  of  the  patient  as 
to  the  division  of  responsibility  among  several  nurses.  Errors  in  the 
diet  or  in  the  collection  of  the  urine  must  be  promptly  traced  to  their 
source. 

While  inaugurating  the  plan  of  treatment  for  a  new  diabetic 
patient,  we  physicians  may  well  take  t;>  heart  the  criteria  which 
serve  as  a  guide  to  V\*.  J.  Mayo  in  his  selection  of  the  technic  to  be 
adopted  in  a  given  surgical  case — namely,  the  eii'ect  of  the  method 
upon  (1)  the  immediate  mortality;  (2)  the  permanence  of  the  relief 
afforded,  and  (o)  the  resulting  disability.  Formerly  we  sinned  most 
against  the  first  rule,  but  now  we  are  often  found  guilty  of  breaking 
the  second  and  third. 

The  treatment  of  a  patient  with  diabetes  lasts  through  life. 
Treatment  must  therefore  be  adjusted  to  this  condition  and  should 
be  so  arranged  that  it  can  be  continued  for  years  without  harm. 
Consequently,  the  patient  must  be  taught  the  nature  of  his  disease 
and  how  to  conquer  it.  Clinicians  with  a  large  clientele  of  diabetic 
patients  have  almost  invariably  been  in  the  habit  of  giving  their 
patients  printed  matter  in  order  to  acquaint  them  with  the  character 
of  the  disease  and  how  to  control  it.  Allen  has  gone  a  step  further  by 
adding  to  didactic  treatment  the  practical  instruction  of  every 
patient  in  the  simple  urinary  tests  for  sugar  and  diacetic  acid. 

The  instruction  of  the  patient  should  not  end  with  urinary  tests: 
it  should  include  didactic  and  practical  instruction  in  the  prepara- 
tion of  his  diet.  In  hospitals  there  should  be  daily  lessons.  The 
patient  is  at  school  to  learn  how  to  save  his  life.  Time  should  be 
taken  at  the  beginning  of  treatment  to  thoroughly  describe  to  the 
patient  the  plan  of  procedure  and  the  necessity  of  his  being  under 
close  observation  until  the  urine  is  sugar-free  and  until  he  under- 
stand- how  to  keep  it  so.  The  diabetic  patient  should  be  made 
to  realize  that  he  has  a  lesson  to  learn,  and  the  earlier  he  learns  it, 
the  sooner  he  can  be  discharged.  Time  also  will  be  saved  and  many 
advantages  accrue  if  a  diabetic  nurse  accompanies  the  patient  to  his 
home  and  supervises  the  diet  for  one  or  more  weeks  under  conditions 
peculiar  to  his  household.  Moderate  changes  in  diet  may  improve 
the  condition  of  a  patient  so  much  that  unless  he  understands  the 


302  TREATMENT 

whole  situation,  ho  may  bo  contented  with  partial  improvement  and 
not  care  to  make  the  efl'ort  to  remain  sugar-free.  At  each  visit  a 
specimen  of  the  twenty-four-hour  quantity  of  urine  should  be 
brought,  or  better  sent,  in  advance,  together  with  a  written  list  of  the 
character  and  weighed  quantities  of  the  food  eaten  during  the  same 
period.  So  soon  as  carelessness  in  this  regard  is  condoned,  indiffer- 
ence to  other  advice  follows.  The  advantages  of  having  the  patient 
bring  a  written  diet  list  are  twofold:  (1)  it  is  more  accurate,  and  (2) 
it  saves  an  enormous  amount  of  the  physician's  time  (see  p.  477). 
The  changes  in  weight  of  the  patient  should  be  recorded.  The 
specimen  of  urine  should  be  that  of  the  twenty-four  hours  immedi- 
ately preceding  the  visit,  but  if  it  is  not,  do  not  neglect  to  immediately 
secure  and  test  a  specimen.  In  diabetes  one  cannot  be  in  too  close 
touch  with  the  actual  condition  of  the  patient  at  the  moment. 

The  advantages  of  hospital  as  compared  with  ambulatory  treat- 
ment are  discussed  on  pages  49)3  to  502,  and  under  the  captions 
"Directions  for  Patients"  and  "Directions  for  Xurses"  on  pages 
47(i  and  477  is  included  material  which  in  order  to  avoid  repetition  is 
omitted  here.  Formerly  physicians  hesitated  to  instruct  all  their 
patients  to  make  urinary  tests,  and  though  I  began  this  method  years 
ago,  I  did  not  persist  in  it.  The  plan  often  proved  unsatisfactory, 
because  so  frequently  disappointment  followed  the  reappearance  of 
sugar  and  it  was  difficult  to  keep  the  patient  sugar-free.  Now  the 
situation  is  different.  Case  Xo.  Mo,  seven  years  of  age,  was  able  not 
only  to  examine  his  own  urine  but  that  of  other  patients  in  the 
hospital,  and  ( 'ase  Xo.  901 ,  a  little  girl  of  four  years,  takes  for  granted 
that  the  diet  will  be  changed  when  she  sees  her  own  urine  give  a  posi- 
tive Benedict  test.  Case  Xo.  995,  aged  six  years,  glories  in  the  fact 
that  his  Benedict  test  is  better  than  that  of  some  of  the  other 
patients.  Patients  weary  of  testing  the  urine,  but  only  under  very 
exceptional  circumstances  should  they  be  allowed  to  omit  making  the 
test.  A  daily  negative  Benedict  reaction  gives  confidence  and,  on 
the  other  hand,  in  the  presence  of  danger,  it  is  never  wise  to  follow 
the  habits  of  the  ostrich. 

The  dietetic  treatment  of  diabetes  is  only  successful  when  the 
urine  of  the  patient  is  free  from  sugar,  the  blood  sugar  normal,  and 
the  blood  lipoids  as  well.  That  the  first  of  these  conditions  should 
hold  has  been  universally  recognized  for  years,  but  it  is  only  since 
Dr.  Allen  introduced  prolonged  fasting  in  the  treatment  that  it  has 
l)een  easy  for  the  general  practitioner  to  secure  this  result  in  prac- 
tically all  cases.  The  increasing  belief  that  the  nature  of  diabetes  is 
more  functional  thi.n  organic  in  character  has  given  a  new  impetus 
to  treatment,  and  has  emphasized  the  importance  which  Xaunyn 
laid  upon  sparing  a  diseased  function,  earlier  recognized  by  Hoffman 
as  a  general  rule  for  the  treatment  of  functional  disorders.  Most  of 


DIETETIC   TREATMENT  303 

this  function  is  evident  if  the  blood  sugar  is  normal  and  the  urine  of 
the  patient  is  sugar-free. 

In  what  follows,  treatment  is  based  on  urinary  examinations, 
and  to  a  lesser  extent  on  the  estimation  of  the  blood  sugar.  The 
study  of  the  blood  lipoids  is  in  its  infancy  and,  though  of  much 
value  in  a  broad  sense,  it  is  seldom  as  yet  therapeutically  useful  in 
the  individual  ease.  Even  examinations  of  the  blood  sugar  are  not 
yet  sufficiently  simple  to  be  available  to  most  physicians,  and, 
furthermore,  not  enough  experience  has  been  gained  to  indicate 
arbitrarily  how  one  should  proceed  when  the  urine  has  become 
sugar-free  and  the  blood  sugar  is  persistently  high. 

The  introduction  of  prolonged  fasting  and  the  new  horizon  which 
this  opened  up  for  fruitful  scientific  investigation,  have  changed 
the  treatment  of  diabetic  patients  from  a  duty  to  a  pleasure.  The 
simplicity  of  the  method  shows  its  worth,  and  that  it  is  safe  for  the 
overwhelming  majority  of  patients  is  attested  by  the  low  mortality 
which  has  followed  its  use.  But  it  must  not  be  forgotten  that  the 
first  year  of  diabetes  following  the  discovery  of  the  disease  is  the 
diabetic's  danger  zone.  The  first  series  of  statistics  of  the  Massa- 
chusetts General  Hospital  from  1824  to  1898,  the  second  series 
between  1898  and  1913,  the  records  of  Griesinger,  Xaunyn  and  my 
own  statistics  prior  to  1910,  demonstrate  this  by  showing  that  68 
JXT  cent,  formerly  (Table  Xo.  15,  p.  33)  and  17  per  cent,  recently 
(Table  Xo.  21,  p.  36)  of  the  fatal  cases  of  diabetes  succumbed  during 
the  first  year  of  the  disease.  Yet  diabetes  is  an  out-and-out  chronic 
disease,  and  the  greatest  mortality  from  it  should  occur  not  in  the 
first  year  following  its  discovery  but  in  later  years.  It  is  my  firm 
belief  that  the  first  year  of  a  diabetic's  life  should  be  his  safest,  and 
that  the  reason  that  this  has  not  been  the  case  is  best  explained  by 
the  method  of  treatment  to  which  he  has  been  subjected  rather  than 
to  a  lack  of  treatment.  In  line  with  this  supposition  is  the  fall  in 
mortality  during  the  first  year  of  the  disease  among  my  cases, 
from  16.9  per  cent,  for  the  year  ending  l)eceml>er  1,  191.3,  to  14.8 
per  cent,  for  the  year  ending  December  1,  1916.  The  second  year 
of  the  disease  now  becomes  my  diabetic  danger  zone,  and  with  this 
change  in  conditions  new  problems  arise. 

This  improvement  in  treatment  in  my  own  series  of  cases  1 
attribute  first  and  foremost  to  fasting,  and  second  to  a  better 
recognition  of  how  to  safeguard  its  use.  I  have  endeavored  to  make 
fasting  treatment  safe  as  well  as  simple  by  preparatory  treatment, 
by  which  I  mean  the  omission  of  fat,  the  gradual  reduction  and  final 
omission  of  protein  and  then  continued  reduction  of  carbohydrate 
with  eventual  fasting  if  required.  This  is  not  necessary  for  some 
cases,  but  it  is  advised  in  all  severe,  long-standing,  complicated,  obese, 
and  elderly  cases,  and  also  in  all  those  showing  aeidosis. 


304  TREATMKXT 

Sixty  per  cent.,  formerly  two-thirds,  of  all  the  fatal  eases  of 
diabetes  I  have  seen  have  died  in  diabetic  coma.  In  all  but  one  of 
the  fatal  cases  in  children  death  has  been  due  to  coma.  My  records 
show  that  of  all  those1  diabetic  patients  who  have  succumbed  to  the 
disease  during  the  first  year  of  itscourse,comahasclaimed  Xi2perccnt., 
formerly  S(i  per  cent.  If  the  first  year  of  the  disease  is  the  patient's 
danger  /one,  it  can  be  as  truly  said  that  the  danger  and  almost  the 
only  danger  is  coma,  and  brushing  aside  all  technicalities,  coma  must 
be  considered  from  the  practitioner's  stand-point  as  synonymous  with 
acid  poisoning.  Therefore,  in  the  plan  of  treatment  which  follows 
it  will  be  seen  that  from  beginning  to  end  the  prevention  and 
treatment  of  acid  poisoning  is  constantly  kept  in  mind.  If  aeidosis 
exists  when  the  patient  comes  for  treatment  he  must  be  in  daily 
communication  with  his  physician.  In  the  past  it  has  not  been  so 
very  unusual  for  a  patient  apparently  in  fair  health,  upon  beginning- 
treatment,  to  fall  into  coma  (Case  Xo.  473,  page  300),  and  so,  too, 
patients  upon  leaving  the  hospital  likewise  in  good  condition, 
though  on  a  restricted  diet,  have  also  died  a  few  days  later  in  coma. 
(Case  Xo.  317,  page  .170;  Case  Xo.  074,  page  34-1.) 

12.  Author's  Flan  of  Campaign  against  Diabetes.  -Xever  before  has 
the  plan  of  campaign  for  the  treatment  of  diabetes  appeared  to  me 
so  clearly  defined  and  never  before  have  I  entered  upon  it  with  as 
much  hopefulness.  The  principles  which  I  keep  before  me  are: 

1.  The  prevention  of  aeidosis — in  large  measure  accomplished 
by  the  omission  of  fat  from  the  diet  at  the  beginning  of  treatment, 
and  the  prompt  treatment  of  aeidosis  by  similar  means  should 
that  subsequently  develop. 

12.  The  attainment  of  a  substantial  positive  carbohydrate  balance 
for  each  patient,  remembering  that  the  owner  of  a  carbohydrate 
tolerance  and  the  owner  of  riches  have  much  in  common,  for  it  is  as 
true  of  one  as  of  the  other,  that  "whosoever  hath,  to  him  shall  be 
given;  but  whosoever  hath  not,  from  him  shall  IK:  taken  away  even 
that  which  lie  hath." 

3.  The  simplification  of  treatment,  the  better  education  of  t!ie 
patient  and  closer  cooperation  with  his  physician. 

4.  The  avoidance  of  inanition,  not  to  be  confused  with   loss  of 
weight,  by  the  protection  of  body  protein  and  greater  care  in  the 
employment  of  fasting.      Fasting  resembles  in  its  action  our  best 
drugs:  morphin  and  digitalis.     These  frequently  give  surprisingly 
good    results   even   when    they   are   carelessly   employed,    but   they 
often  do  harm,  and  their  true  worth  is  only  disclosed  when  they  are 
prescribed  with  intelligence.     Furthermore,  if  inanition  or  a  tendency 
to  inanition  and  hunger  can  be  avoided,  a  smaller  number  of  patients 
will  yield  to  temptation,  break  treatment   and   in  consequence  die 
of  coma. 


DIETETIC    TREATMENT  1505 

3.  Summary  of  Dietetic  Treatment. — It  will  conduce  to  clearness 
to  summarize  the  routine  plan  of  treatment  now  employed  by  the 
writer,  and  subsequently  to  discuss  its  general  phases  and  the 
exceptions  to  it  which  occasionally  must  be  made.  By  this  method 
the  patient  usually  becomes  sugar-free  within  a  few  days,  and 
acidosis,  if  present,  disappears.  Alkalis  are  unnecessary,  and  if 
given  do  harm. 

Preparation  for  Fasting. — In  severe,  long-standing,  complicated, 
obese,  and  elderly  cases,  as  well  as  in  all  cases  with  acidosis,  or  in 
any  case  if  desired,  without  otherwise  changing  habits  or  diet, 
omit  fat,  after  two  days  omit  protein,  and  then  halve  the  carbo- 
hydrates daily  until  the  patient  is  taking  only  10  grains;  then  fast. 
In  other  cases  begin  fasting  at  once. 

Fasting. — Fast  four  days,  unless  earlier  sugar-free.  Allow  water 
freely,  tea,  coffee,  and  thin,  clear  meat  broths  as  desired. 

Intermittent  Fasting. — If  glycosuria  persists  at  the  end  of  four 
days,  give  1  gram  protein  or  0.5  gram  carbohydrate  per  kilogram 
body  weight  for  two  days,  and  then  fast  again  for  three  days  unless 
earlier  sugar-free.  If  glycosuria  remains,  repeat  and  then  fast  for 
one  or  two  days  as  necessary.  If  there  is  still  sugar,  give  protein 
as  before  for  four  days,  then  fast  one,  and  then  gradually  increase 
the  periods  of  feeding,  one  day  each  time,  until  fasting  one  day  each 
week.  I  have  seen  no  uncomplicated  case  fail  to  get  sugar-free  by 
this  method. 

Carbohydrate  Tolerance. — When  the  twenty-four-nour  urine  is 
free  from  sugar  give  5  to  10  grams  carbohydrate  (15;)  to  oOi)  grams 
of  5  per  cent,  vegetables)  and  continue  to  add  ~>  to  10  grams  carbo- 
hydrate daily  up  to  •">()  grams  or  more  until  sugar  appears. 

Protein  Tolerance. — When  the  urine  lias  been  sugar-free  for  three 
days,  add  about  20  grams  protein  and  thereafter  lo  grains  protein 
daily  in  the  form  of  egg-white,  fish  or  lean  meat  (chicken)  until  the 
patient  is  receiving  1  gram  protein  per  kilogram  body  weight,  or 
less  if  the  carbohydrate  tolerance  is  zero. 

Fat  Tolerance. — Add  no  fat  until  the  protein  reaches  1  gram  per 
kilogram  body  weight  (unless  the  protein  tolerance  is  below  this 
figure)  and  the  carbohydrate  tolerance  has  been  determined,  but 
then  add  5  to  2.">  gram:;  daily,  according  to  p:'evious  acidosis,  until  the 
patient  ceases  to  lose  weight  or  receives  in  the  total  diet  about  oO 
calories  per  kilogram  body  weight. 

Reappearance  of  Sugar. — The  return  of  sugar  demands  fasting  for 
twenty-four  hours,  or  until  sugar-free.  Resume  the  former  diet 
gradually  adding  fat  last  in  order  to  maintain  as  high  a  carbo- 
hydrate tolerance  as  possible,  sacrificing  body  weight  for  this  purpose. 

Weekly  Fast  Days. — Whenever  the  tolerance  is  less  than  20  grams 
carbohydrate,  fasting  should  be  practised  one  day  in  seven;  when 
20 


306 


TREATMENT 


the  tolerance  is  over  20  grains  carbohydrate  cut  the  diet  in  half 
on  one  day  each  week. 

The  foods  commonly  employe1:!  in  determining  the  tolerance  for 
carbohydrate  and  protein  are  f)  per  cent,  vegetables,  oranges, 
oatmeal,  potato,  fish,  chicken  (lean  meat).  (For  the  food  values  of 
these  and  other  foods,  see  Table  120.) 

A  common  course  of  treatment  when  a  new  patient  (Miters  the 
hospital  is  to  prescribe1  ">  percent,  vegetables  (150 grams)  and  a  small 
orange  at  each  meal,  if  uncertainty  about  the  character  of  the  case 
exists,  but  otherwise  to  commence  fasting  at  once.  To  avoid  repeti- 
tion, illustrative  cases  are  inserted  on  later  pages  where  the  treatment 
is  described  more  in  detail.  (See  Tables  142,  14/5,  144,  145,  140,  and 
other  tables  in  Section  VI.) 

TABLE   141. — II.I.I-STKATIOX  OF  AMBULATORY  TREATMENT  WITHOUT  FASTING 

OR  OMISSION  OF  PUOTEIX.     CASE  Xo.  1237.     ACE  AT  ONSET  ix 

SEPTEMBER,  o!(  YEARS  AND  5  MONTHS. 


Dietary  proscriptions  in  ura.n 


It  is  by  no  means  necessary  to  follow  this  same  program,  and 
recently  the  following  simple  schedule  worked  admirably  with  an 
ambulatory  patient.  (Table  111.)  It  had  the  advantage  of  avoiding 
reduction  of  protein  for  even  a  single  day.  ( 'ase  No.  12l>7,  age  at  onset 
thirty-nine  years,  presented  himself  for  treatment  a  year  and  a  half 
later,  and  without  acidosis,  but  with  '>•><>  grams  sugar  in  the  urine 
during  twenty-one  hours.  The  directions  given  may  be  summarized 
as  follows:  Take  one-half  pound  (240  grams)  5  per  cent,  vegetables, 
one-quarter  of  a  pound  fish  (120  grams),  and  one  small  orange  at 


DIETETIC   TREATMENT  307 

a  meal  for  two  days;  on  the  third  day  omit  half  and  on  the  fourth 
day  all  the  orange.  When  sugar-free,  exchange  one-quarter  pound 
fish  for  3  ounces  meat,  and  next  replace  another  quarter  pound  fish 
by  2  eggs;  then  replace  2  eggs  with  2  ounces  bacon  and  subsequently 
add  one-half  ounce  butter  a  day  for  two  days,  to  be  followed  every 
other  day  by  the  addition  of  an  ounce  of  20  per  cent,  cream  until  3 
are  taken.  Similarly,  thereafter  every  other  day  add  one-half  orange 
until  one-half  is  taken  at  a  meal  and  from  then  on  every  other  day 
1  ounce  potato  until  as  much  as  desired  is  taken,  or  sugar  appears. 

4.  Details  of  Treatment. — It  is  recognized  that  the  above  outline 
of  treatment  is  purely  schematic,  and  that  it  should  be  adapted  to 
the  weight,  age,  digestion  and  tastes  of  the  individual  patient. 

The  dietary  charts  and  urinary  records  of  various  recent  cases 
illustrating  the  plans  of  treatment  above  outlined  are  to  be  found 
on  pages  308  and  309.  It  will  now  be  in  place  to  discuss  in  detail 
the  above  methods  of  procedure,  which  constitute  the  diabetic 
pharmacopoeia. 

(a)  Preparation  for  Fasting. — It  is  not  only  more  rational,  but 
it  is  easier  to  prevent  acidosis  than  to  treat  it.  This  is  the  reason 
for  the  preparation  for  fasting.  The  majority  of  diabetic  patients 
show  little  acidosis  upon  fasting,  or  if  this  has  been  present  it  will 
decrease.  (Table  144,  page  309.)  On  the  other  hand,  it  is  not  always 
easy  to  predict1  what  will  occur,  and  an  acidosis  which  has  not  been 
present  may  appear  or  an  existing  acidosis  may  grow  worse.  There- 
fore it  is  safer  to  take  pains  to  avoid  the  development  of  acidosis  in 
those  predisposed  to  it,  for  it  is  a  sound  rule  of  all  treatment  that 
patients  coming  to  the  physician  in  an  endurable  state  must  not  be 
made  worse  or  have  their  lives  jeopardized  by  the  therapeutic 
procedures  adopted. 

Individuals  predisposed  to  acidosis  are  those  in  whom  the  disease 
is  of  long  duration.  These  are  the  patients  who,  after  having  lived 
in  a  fairly  comfortable  condition  for  years,  succumb  when  placed 
upon  a  fat-protein  diet.  The  last  case  of  this  kind  in  my  own 
experience  was  a  very  severe  one  (Case  Xo.  SS7,  page  3o9),  who 
had  had  diabetes  twenty-nine  years,  and  is  described  in  full  under 
Cases  Unsuccessfully  Treated  by  Fasting  (page  350).  Contrast  this 
case  with  the  following  two  cases. 

Case  Xo.  979,  a  woman,  aged  forty-nine  years,  developed  diabetes 
at  the  age  of  thirty-two.  When  I  first  saw  her,  seventeen  years 
later,  January  2(5,  191(5,  she  showed  7.4  per  cent,  of  sugar  and  no 
diacetic  acid.  It  \vill  be  seen  from  Table  142  how  she  became  sugar- 
free  without  the  development  of  acidosis  by  the  elimination  of  fat 
and  the  restriction  of  protein,  followed  by  the  gradual  diminution 
of  carbohydrate. 

:  Stillman:  Am.  Jour.  Med.  Sc.,  1916,  cli,  p.  505. 


308 


TREATMENT 


TABLE  142. — CASE  No.  979  OF  SEVENTEEN  YEARS'  DURATION,  ILLUSTRATES 
IIo\v  PREPARATORY  TREATMENT  MAKES  FASTING  UNNECESSARY. 


Date, 

191(1. 

Urine. 

Diet  in  gran  s. 

0 

Dietary  prescriptions  in  grains. 

Sugar. 

•3 

| 

n.~ 

"      "3 

0           n 

i       -c     IVr   Total 
5        2  |  cent.   KIMS 

>. 

C 

1 

+J 

ed 

"c 

Calories 

"u 
'3 

Vegetal) 
5  per 

Ui    C 

2 

•a 

a 

*a 
"?, 

fc4 

0 

In 
•*> 

0 

1 

J;in. 

25 
25-20 

21)  27 

.  .      0    7.4 
0    f>  2     54 

0 

0 

944 

13()i 
12S 

300 

1  1. 

0    90 

100 

1 

90 

6 

1475  '()    5.(>     S3 

142    IS    10 

27   2S 

1700    0    4.0     70 

112  :  43 

10    0    7(54 

12S 

300     1     1. 

0    1)0      50    1    !)()    0 

2.S-2!) 

1200    0    2.2     20 

72    3S    10    ()    5S4 

12S 

300    1     2. 

0    '.)()         0    0    90  ;  (i 

20  30 

1350    0    1.0     14 

50    2S    11    0    411 

127 

300    1     1. 

0    30        0    0    00 

G 

30  31 

1350    0    0.0       ,S 

40    2S    11    0    371 

127 

300    1    0. 

0    30        0    0    00 

6 

Feb. 

31-   1 

1200    0    0.2       2 

25    20 

5    0    249 

120 

300    0    0 

5    30        0    0    20 

0  40 

1—  2 

.  .     .  0    0.0       0 

25    27      SO    2SO 

120 

300    0    0 

5    30        0    0    40 

0  20 

1917 

Feb.  Hi 

.    Tr.        0 

All)Uin  in     eonsiderab 
I 

le. 

1 

Case  No.  1007,  of  fifteen  years'  duration,  aged  forty  years  at 
onset,  was  even  more  favorable,  because  in  three  days  she  easily 
became  sugar-free,  as  is  shown  in  Table  143. 

By  the  elimination  of  fat,  followed  by  the  rapid  reduction  of 
protein  and  the  gradual  reduction  of  carbohydrate,  she  became 
sugar-free  without  the  development  of  acidosis,  and  fasting  was 
rendered  unnecessary. 

All  complicated  cases,  especially  those  in  which  the  complication 
involves  the  kidneys,  heart  (see  Xo.  759,  Tables  217,  2 IS)  or  thyroid 
demand  preparatory  treatment,  for  they  are  especially  susceptible 
to  acidosis.  Case  Xo.  S(>9,  p.  3C>2,  with  high  blood-pressure  and 
goitre  is  the  last  fatal  case  of  this  type  which  has  come  to  my 
attention,  and  is  also  described  in  the  section  on  I'nsuccessful  Cases. 
In  this  group  are  also  included  elderly  patients,  because  of  their 
vulnerable  kidneys.  Very  fat  diabetics  could  appropriately  be 
included,  because  of  the  tendency  of  even  normal  individuals  who 
are  very  fat  to  develop  acidosis,  as  shown  by  Folin  and  Denis,  and 
so,  too,  patients  about  to  undergo  surgical  operations.  Finally, 
patients  showing  signs  of  acid  poisoning  are  benefited  by  this 
preparatory  treatment  before  the  fast,  but  if  they  have  been  accus- 
tomed to  a  low  diet  I  proceed  with  fasting  at  once.  Such  an  instance 
was  Case  Xo.  102")  (see  p.  300),  who  was  fasted  for  five  days.  The 
patient  was  a  girl  aged  twenty-one  years,  with  onset  of  diabetes  a 
year  before.  She-  had  lived  upon  a  fairly  restricted  diet,  and  despite 
the  acidosis  she  impressed  me  so  favorably  that  1  decided  to  fast 


DIETETIC  TREATMENT 


309 


•!>inosiq 

'•Bp89OjfJ 

CO 

•uoocg 

U5 

•joying 

O 
CO 

•VoOjv 

C       O 
0        IN 

- 

•833g 

01        C-I 

s 

be 

•}uoo  Jji-i  Of- 
'ureajQ 

0       0 
CO      'CM 

O 

'1IS!.>I 

CO       O 

C". 

.s- 

•p30Ur»T!O 

i.O       OO       O   , 
rH        COCO        CO 

a 

hi 

•fm^oj 

OOO            O       O       OO       O 

-r  •-•  i 

•M  —i 

C 

•^nujodcjQ 

--H-H            0       OSOO       0 

•oSuuj() 

O                                       ?       '"       O 

•00            00  £,0^;       ^; 

•;uao  jod  oi 
'sa[qT!;oSio  v 

OOO            O       OoOO       O 
iO  O  i«                              £ 

^  I~H                         *^ 

•^uaa  jod  g 
'sa^qB^oao  \ 

S!?:?      8    °    CS    S 

I—  •-<  ^H                     CO                                      T-^            CO 

•eqi  '^qSiOAV 

-r  co  co  N     '^    .        .        .    .     o 

If 

-r  x  o         o     "-1     c  c-.     i  - 

X  -M  ^1            —       —       Cv  O       I-H 

'COC-ll-H       .       '                                 --I-          0 

m 

4  - 

S.'o 

:  :  i  :  ~  '.  o    o    o  o    o 

I        I     .-I 

.  it^ci': 

•M  ?)  CM  01  -< 


a  I 

fi  g 

E     P 

p 


2    Q 


•SH  -mm 

•-O     •  ffl  O5  O  O  Ci  —i  O 

3  Jib  JT.[OOAJV 

•uignui 

aa^sA'j 

•  )uoj  jod  of- 

'UIBOJQ 

•03U13J() 


•juoo  jod  o 


COO  OO  O 


ooooooooo     o 


O  O  O  O  O  "O  O  O  O       IN 


OO 

•  >  o 

r       ^) 


310  TREATMENT 

her  at  once.  Table  1  H-  shows  how  successful  this  proved  to  be, 
both  as  regards  sugar  and  aeidosis. 

The  principle  upon  which  preparatory  treatment  is  based  is  the 
exclusion  of  the  source  of  the  acid  poisoning.  Since  the  chief  source 
of  acid  poisoning  is  fat,  this  constituent  of  the  diet  is  prohibited. 
If  this  is  done  the  opportunity  for  the  patient  to  develop  acid  poison- 
ing is  greatly  reduced,  and  for  two  reasons:  (1)  the  chief  source 
of  acid  bodies  is  removed,  and  no  fat  is  then  available  for  the  for- 
mation of  acid  bodies  except  the  fat  of  the  body;  (2)  in  conse- 
quence of  the  partial  fast,  which  is  thereby  inaugurated,  the  pos- 
sibility of  oxidation  of  some  of  the  carbohydrate  which  the  patient 
is  eating  is  favored,  and  if  this  should  fortunately  take  place, 
aeidosis  is  sure  to  decrease.  So  strongly  have  I  been  impressed 
by  the  stormy  career  of  the  diabetic  patients  in  whose  diet  carbo- 
hydrates have  been  suddenly  restricted  and  fat  increased,  in  contrast 
to  the  placid  course  which  those  pursue  from  whose  diet  fat  has 
been  excluded  and  the  carbohydrates  left  unchanged,  that  whenever 
I  am  asked  to  see  a  new  case  of  diabetes  I  beg  the  physician  either 
not  to  change  the  diet  at  all  or  to  simply  omit  the  fat  until  the 
consultation  takes  place.  A  little  child,  Case  \o.  86"),  page  3~)0, 
is  the  last  case  of  this  type  which  has  proved  fatal  and  is  described 
with  the  I  nsuccessful  Cases.  Today  I  am  convinced  that  if  I 
had  instructed  the  physician  to  treat  the  patient  according  to  the 
above  outline,  five  days  later  when  the  patient  was  brought  to  the 
hospital,  coma  Avould  not  have  ensued.  I  feel  amply  justified  in 
making  this  assertion  from  experience  with  other  cases  of  similar 
age  seen  both  before  and  since  that  date.  \\e  must  all  recognize 
the  dangers  of  fat  to  the  diabetic. 

Knerr1  begins  the  treatment  of  his  cases  by  giving  a  teaspoonful 
of  uncooked  starch  in  a  glass  of  warm  water  every  two  hours  and 
accomplished  in  this  fashion  much  the  same  object  as  above 
described,  lie  observed  that  both  glycosuria  and  aeidosis  gradually 
decreased  and  that  by  this  simple  means  the  use  of  alkalis  and  the 
danger  of  coma  were  avoided. 

The  days  of  preparation  for  the  fasting  are  also  advantageous  in 
that  they  allow  the  patient  to  become  acquainted  with  the  plan  of 
treatment;  fasting  and  a  hospital  he  fears.  Opportunity  is  also 
afforded  for  the  doctor  to  thoroughly  examine  the  general  condition 
of  the  patient.  This  must  never  be  lost  sight  of  at  the  beginning  of 
treatment.  It  is  absurd  to  feed  a  patient  without  teeth  with  coarse' 
vegetables,  or  to  give  these  to  another  patient  who  has  diarrhea. 
Another  form  of  carbohydrate  must  be  chosen,  but  whether  this  is 
potato,  oatmeal,  shredded  wheat,  puree  vegetables,  or.  in  case 

*  Kiii'rr:   Missouri  State  Mod.  Assn.  Jour.,   1'Jl'j,  xii,  p.  71. 


DIETETIC   TREATMENT  311 

protein  is  employed,  a  few  oysters,  whites  of  eggs,  or  boiled  fish, 
is  a  matter  of  indifference. 

The  bowels  must  be  thoroughly  opened,  but  I  do  not  believe 
in  free  eatharsis.  If  the  patient  has  not  had  a  movement  for  several 
slays,  give  an  enema,  followed  by  some  simple  cathartic  or  mild 
aperient,  and  another  enema  twelve  or  twenty-four  hours  later, 
but  do  not  purge  the  patient.  Gain  enough  is  obtained  if  a  move- 
ment is  produced  once  in  twenty-four  hours  when  it  has  only  been 
taking  place  once  in  seventy-two.  In  other  words,  do  not  upset 
any  patient  who  is  in  a  tolerable  state.  Furthermore,  allow  the 
patient  to  continue  his  regular  routine,  avoiding  excess  in  any 
direction.  Remember  what  happens  to  an  old  man  who  is  suddenly 
confined  to  bed,  and  the  discomfort  which  follows  confinement 
following  a  fracture.  Do  not  force  a  temperate  man  to  drink  against 
his  will. 

An  advantage  which  the  omission  of  fat  from  the  diet  affords 
is  the  rest  which  is  given  to  the  digestive  tract.  Former  treatment, 
which  increased  the  fat  in  the  diet,  was  the  converse  of  this,  and 
frequently  led  to  vomiting,  with  the  result  that  patients  on  the 
verge  of  coma  fell  into  it.  In  every  way  seek  to  prevent  worry  on 
the  patients'  part,  and  from  the  start  give  them  to  understand  that 
they  are  at  school  rather  than  at  hospital. 

Following  the  omission  of  fat  from  the  diet  comes  the  exclusion 
of  protein.  From  protein  comparatively  few  acid  bodies  are  formed, 
but  it  is  safe  to  avoid  even  these,  and  at  the  same  time  gradually 
approach  the  fasting  treatment.  Detailed  observations  upon  the 
advantage  of  restricting  protein  at  this  stage  would  be  advantageous. 
I  may  have  erred  in  the  restriction  of  protein.  Note  the  easy 
course  which  Case  Xo.  1237,  p.  206,  took  in  becoming  sugar-free 
while  protein  was  maintained  at  a  normal  level  throughout. 

(b)  Fasting. — Fasting  is  never  so  rigorous  as  doctors  or  patients 
expect.  Patients  are  more  ready  to  undergo  it  than  physicians  to 
prescribe  it.  Quite  as  often  it  is  as  much  a  relief  to  the  patient  as 
it  is  discomfort.  This  is  in  part  due  to  the  gradual  decrease  in 
polydipsia  and  polyuria.  Headache  occurs  less  frequently  than 
would  be  expected,  and  is  usually  dispelled  by  a  cup  of  coffee. 
Xausea  almost  never  occurs  unless  a  patient  is  given  alkali  or 
alcohol.  Children  bear  it  more  easily  than  adults.  Case  Xo.  799, 
with  onset  at  eighty-three,  shunned  it  and  rightly,  but  she  became 
sugar-free  and  now,  two  years  later,  is  vigorous  and  remains  sugar- 
free.  It  is  always  desirable  to  avoid  fasting  in  the  old,  and  this  can 
be  accomplished  usually  by  the  help  of  preparatory  treatment. 

Fasting  does  not  seem  like  fasting  to  the  patients  when  they 
receive  coffee,  tea,  cracked  cocoa,  cocoa  shells  and  broths,  and  are 
given  an  unlimited  supply  of  water.  \Varm  drinks  are  preferable. 


312  TREATMENT 

It  the  quantity  of  urine,  as  it  often  does,  falls  to  less  than  normal, 
the  patients  are  urged  to  drink  water  freely.  Clear  meat  broths  are 
a  great  satisfaction.  An  analysis  of  the  1220  c.c.  of  broths  taken  by 
( 'ase  Xo.  7(1-")  during  three1  days  showed  the  total  amount  of  calories 
therein  contained  to  be  negligible.  Contrary  to  my  experience  with 
digestive  cases,  broths  do  not  stimulate  the  appetite  in  fasting 
diabetics;  they  relieve  it.  (See  p.  271.)  The  advantage  of  broths 
is  probably  due  in  part  to  this,  but  to  a  considerable  extent  to  the 
patient  receiving  salt  by  which  he  may  maintain  the  equilibrium 
of  body  fluid.  In  the  case  just  cited  the  1220  c.c.  broths  contained 
10.7  grams  salt  and  the  patient  took  12  grams  more  from  the  salt- 
cellar. It  is  passible  that  the  salt  is  a  more  important  factor  in  the 
treatment  than  has  been  supposed.  There  is  an  urgent,  need  for  an 
accurate  study  of  this  phase  of  the  subject.  (Sec  p.  2S.~>.) 

Patients  should  not  be  kept  abed  during  fasting,  neither  should 
they  be  forced  to  be  up  all  day.  Reclining  in  a  steamer  chair  requires 
no  more  exertion  than  rest  in  bed.  They  should  be  afforded  diversion 
by  visits  from  friends,  walking  short  distances,  easy  handiwork, 
playing  games,  letter  writing,  and  reading.  In  general  they  are 
glad  to  rest  for  the  greater  part  of  the  first  day  of  the  fast,  but  upon 
each  succeeding  day  I  have  noticed  that  they  are  desirous  to  increase 
the  amount  of  exercise.  Case  Xo.  70")  (see  page  o!4),  a  trained 
diabetic,  who  returned  to  the  hospital  in  order  to  become  sugar- 
and  acid-free,  at  the  end  of  three  and  one-half  days  of  fasting, 
enjoyed,  without  fatigue,  going  to  the  theatre.  1  confess  this  was 
not  with  my  advice,  for  I  have  endeavored  to  prevent  exposure  of 
diabetic  patients  from  infection  during  fasting,  and  indeed,  under 
all  circumstances. 

However,  several  have  developed  intercurrent  infections  during 
fasting  while  in  the  hospital— one  a  tonsillitis,  elsewhere  recorded 
(Case  Xo.  X13,  p.  45!))  and  Case  Xo.  (,)0"),  another  mild  diabetic 
who  acquired  influenza  from  his  neighbor,  and  rigid  dieting  was 
necessary  before  glycosuria  disappeared.  Case  XO.  (,)3S,  a  child, 
aged  t\vo  and  a  half  years,  underwent  fasting  treatment  successfully 
in  the  presence  of  mild  infection  of  the  upper  air  passages.  At  one 
time  a  mild  cory/a  attacked  each  patient  in  a  four-bed  ward.  Today 
any  patient  or  nurse  with  a  "cold"  is  isolated  or  goes  oil'  duty. 
Fortunately  no  infection  developing  after  entraive  to  the  hospital 
has  proven  fatal. 

It  is  surprising  ho\v  variable  is  the  period  required  to  render  the 
urine  sugar-free.  Frequently  a  urine  which  contains  7  per  cent. 
of  sugar  becomes  free  from  sugar  after  fasting  for  four  meals,  and 
conversely,  a  urine  with  only  '•>  per  cent,  of  suti'ar  may  still  retain 
traces  after  the  patient  has  been  deprived  of  food  for  three  or  four 
davs.  In  general,  cases  seen  >oon  alter  onset  become  sugar-free 


DIETETIC   TREA  TMEX T 


313 


promptly,  whereas  the  reverse  is  usually  true  for  those  of  long 
duration.  "  In  one  ease  we  may  be  dealing  with  fatigue;  in  the  other, 
exhaustion  of  an  already  weakened  organ,"  according  to  Greeley.1 
However,  Case  No.  733,  age  at  onset  seventeen,  was  fasted  twenty- 
six  months  later,  when  he  showed  0.0.  per  cent,  of  sugar  and  became 
sugar-free  in  two  days.  The  explanation  in  this  instance  wa* 
apparently  the  fact  that  the  case  was  remarkably  mild,  being 
jf  the  obesity  type;  in  fact,  the  patient's  highest  weight — 11H) 
pounds — was  reached  when  he  first  came  under  observation,  and 
during  the  preceding  twenty-six  months  he  had  gained  twenty-six 
pounds.  (See  page  340  for  the  conclusion  of  this  case.)  Children 
showing  large  amounts  of  sugar  have  also  become  sugar-free  very 
promptly  when  the  duration  has  been  only  a  few  weeks.  Cases  of 
long  standing  appear  to  become  sugar-free  more  quickly  with 
preparatory  treatment  than  with  an  immediate  fast.  This  is 
probably  due  to  the  avoidance  of  acidosis. 


Oct.  lino 


Sept. 


2,-)  26  27   28  •>'.>  30  :!l    I     '      :i     I     :>     (its     !»    10 


FIG.  l.'i. — A  slight  infection  need  not  prevent  fastin::. 


485  and  4SS  for  dietary  and  urinary  charts  of  thi.s  ca-e. 


(c)  Intermittent  Pasting. — The  observation  of  Folin  and  Denis-  that, 
an  individual,  normal  save  for  obesity,  went  through  a  second 
period  of  fasting  with  less  acidosis  than  the  first,  and  the  practice, 

1  Greeley:  Boston  Mod.  and  Rurg.  Jour.,   1910,  clxxv,  p.  753. 

2  Foliu  and  Denis:   Loc.  cit.,  p.  149. 


314  TREATMENT 

observed  by  many  clinicians  of  the  old  school,  who  advantageously 
fasted  their  diabetics  one  day  a  week,  have  given  the  cue  to  inter- 
mittent fasting.  Very  few  of  my  patients  have  been  subjected  to  a 
fast  of  more  than  four  days.  Xo  patient  has  undergone  a  fast  exceed- 
ing nine  days.  Such  a  prolonged  fast  is  unnecessary,  and  even  if 
the  fast  is  carried  out,  it  is  doubtful  if  the  patient  would  always 
become  sugar-free.  The  apparent  reason  for  the  persistence  of 
sugar  in  Case  Xo.  010,  who  fasted  the  nine  days,  v\'as  the-  presence 
of  a  vulvar  abscess.  This  patient  showed  a  carbohydrate  tolerance 
of  only  2  grams  for  the  subsequent  year,  but  upon  readmission 
to  the  hospital  in  May,  1910,  and  the  institution  of  routine  treat- 
ment, she  became'  sugar-free  in  one  day  and  the  tolerance  rose  to 
")•")  grams  carbohydrate  and  an  equal  quantity  of  protein,  and  the 
total  calories  rapidly  reached  over  20  per  kilogram  body  weight. 
The  gain  persisted  until  autumn,  when  it  gradually  decreased,  but 
it  returned  temporarily  with  renewal  of  energetic  treatment  and  the 
use  of  levulose  this  spring. 

Inquiry  among  my  friends  shows  that  an  infection  of  some  kind  is 
usually  present  when  glycosuria  persists  after  a  fast  of  a  few  days' 
duration.  This  is  not  always  the  case,  for  the  difficulty  in  rendering 
the  urine  sugar-free1  may  be  simply  due  to  the  extreme  severity  of  the 
disease. 

Alternate  feeding  and  fasting  are  adopted  when  it  is  found  that 
the  glycosuria  persists  after  a  preliminary  four  days'  fast.  The 
method  which  1  have  found  most  successful  has  been  to  allow  about 
1  gram  protein  or  one-half  gram  carbohydrate  per  kilogram  body 
weight  for  two  days  and  then  fast  again  for  three  days  unless  earlier 
sugar-free.  The  sugar  promptly  increases  in  the  urine,  but  if  one 
averages  the  excretion  of  sugar  in  the  urines  of  these  two  days  with 
the  two  days  at  the  beginning  of  the  fast,  the  result  is  encouraging. 
The  second  fast  is  a  day  shorter  than  the  first,  and  the  second  period 
of  feeding  a  day  longer,  until  by  the  fourth  period  of  fasting  the 
patient  goes  without  food  only  one  day  and  then  is  given  food  for 
four  days.  This  schedule  need  not  be  Followed  exactly,  but  the 
general  plan  has  proved  most  efficacious. 

The  best  example  which  I  have  of  the  advantage  of  intermittent 
fasting  is  Case  Xo.  1190,  that  portion  of  Table  100  from  December 
IS  forward  described  in  full  under  Acidosis.  Case  Xo.  705,  Table 
140,  illustrates  this  also,  but  the  administration  of  levulose,  as  in  the 
earlier  part  of  Case  Xo.  1190,  complicates  the  picture.  The  use  of 
levulose  in  these  and  other  cases  is  discussed  on  page  37X.  Case  Xo. 
1M  ,  recorded  on  page  492, was  the  first  case  so  treated.  ( 'aseNo.  1207, 
Table  140,  shows  clearly  my  present  plan  of  treatment.  Few  if  any 
uncomplicated  cases  of  diabetes  exist  which  will  not  become  sugar- 
free  with  treatment  similar  to  that  of  ( 'asc  Xo.  70.").  During  the 


DIETETIC   TREATMENT 


315 


whole  period,  from  the  first  clay  to  the  thirty-first  day,  she  was  up 
and  about,  and  upon  the  third  day  of  fasting  enjoyed  "a  matinee. 
I  pon  the  remaining  days  she  often  walked  several  miles  a  day,  kept 
in  good  spirits,  and  in  connection  with  one  of  the  instructors  of 

TABLE  145. — INTERMITTENT  FASTING.     CASE  No.  765.    ONSET  AT  21.8  YEARS;  TREATMENT  AT 

22.4  YEARS. 


Urine. 

Diet  in  grams. 

"5 

u 
A 

« 

.§ 

, 

t_ 
c 

Date, 
191(5. 

a 

£ 

>>  £ 

£3     -I 

c 

bt 

C 
rt 
u 

0 

o 

1  p 

**>  "*• 

bD 

'fi 

"  ti 

(H 

V 

^: 
1 

12 

ti 

u 

V 

a 

c 

Diaoetie 
acid. 

J2     - 

>rz 

c  | 

^ 

~  S, 

C3 

A-S 

•£  b 

c 

.£ 
*c 

o 

o  Z 

_3M 

0    - 

d 

* 

0 

R.  Q 

I 
_o 

~5. 

a 

5 

7  ^ 

+*  3 

K 

c  ~ 

=3"~* 

o 

•^ 

"c; 

-5  " 

J2  ~ 

^  ~ 

— 

^ 

N 

o 

y, 

< 

<Q. 

y. 

fc 

H 

O 

« 

fc 

U 

J 

S 

< 

£ 

0 

Q 

O 

•£ 

Jan. 

21-22 

4.0 

0.9 

+  +  + 

5.0 

3.2 

1.0 

67 

11 

40.3 

0.31 

31 

90 

22-23 

7.7 

2.5 

+  +  + 

19.2 

7.1 

3.0 

43 

0 

0 

0 

0 

-43 

80 

129 

177 

0.73 

51.0 

40.1 

20 

so 

23-24 

8.8 

+  +  +  + 

5.9 

2.7 

20 

0 

0 

0 

0 

-20 

78 

40  .  3 

21 

24-25 

10.9 

H  —  1  —  1  —  h 

10.2 

2.6 

15 

0 

0 

0 

0 

-15 

0.25 

109 

155 

0.70 

41  .  6 

40.8 

0  .  20 

24 

54 

2.5-26 

+  +  + 

6.2 

2.6!  37 

89 

lev 

ulose 

35i) 

+52 

0.24 

113 

156 

0.72 

44.9 

3(3 

is 

121 

168 

0.72 

48.4 

20-27 

9.9 

+  + 

6.3 

2.7  i  31 

0 

24 

9 

177 

-31 

40.8 

31 

-.2 

27-28 

12.  S 

+  + 

9.1 

2.9 

34 

0 

40 

15 

295 

-34 

40.9 

0.'25 

32 

18 

28-29 

8.3 

+ 

5.3 

2.1 

10 

0 

0        0 

(i 

-10 

32 

s() 

40.2 

29-30 

7.2 

+  + 

3.6 

1.4 

0 

0 

0        0 

0 

-   0 

i2 

1 

41.4 

o.'i? 

31 

;-t 

30-31 

17.4 

+  + 

8.6 

2.7 

18 

0 

40      25 

38.5 

-18 

11.5 

31 

Feb. 

31-   1 

14.1 

+  + 

7.3 

2.3     20 

0 

40 

25 

385 

-20 

.  .    j    .  . 

41.7 

31 

1-  2 

-4-  -4- 

9.1 

2.5     23 

0 

40 

25 

385 

OQ 

99    139  10  71 

40.0 

42.5 

0  .  20 

33 

2-  3 

+ 

5.3 

1.7       5 

0 

0 

0  i        0 

—    .5 

42.3 

| 

3-  4 

+  + 

5.2ll.8i     4 

0 

0 

0 

0 

-   4 

.  .   !   .  . 

42.3 

| 

0  .  20 

33 

4-  o 

+ 

7  .  0 

2.0 

12 

0 

to 

0 

160 

-J9 

42.7 

30 

5-  0 

81.  + 

8.2 

2.0 

9 

0 

45 

180 

—   9 

43.0 

6-  7 

SI.  + 

8.5 

1.8 

13 

0 

52 

15 

313 

-13 

43.0 

30 

7-  8 

0 

9.0 

1.3 

18 

0 

52 

1.5 

343 

-18 

42.3 

8-  9 

0 

9.1 

1.2 

14 

0 

52 

15 

343 

-14 

41.5 

0.23 

32 

9-10 

SI.  + 

4.0 

0.9 

0 

0 

0 

0 

0 

101    133    0.7G 

38.3 

41.7 

0  .  18 

38 

10-11 

0 

5.4 

0  .  8 

0 

0 

(I 

0 

0 

101    137 

0  .  75 

39  .  5 

41.7 

0.'21 

30 

11-12 

0 

5  .  5 

0.7 

0 

40 

31 

403 

0 

41.3 

30 

12-13 

0 

4.4 

1  .4 

0 

.5 

48 

39 

503 

5 

11.1 

35 

13-14 

0 

0 

5 

34 

52 

624 

5 

37.8 

| 

O.'l9 

14-1.') 

0 

.  .        9.0 

1  .  5  |     0 

0 

63 

75 

927 

0 

38.5 

15  -Hi 

0 

..        8.3 

0 

0 

63 

105 

1197 

0 

38.6 

10-17 

0 

0 

63 

105 

1197 

37 

38.5 

0.20 

17-18 

0 

0.6 

i 

0 

0 

0 

0 

-    1 

38  .  5 

0.17 

18-19 

0 

0.7 

0 

41 

05 

749 

107    141 

0.76 

40.6 

38.5 

20-21 

'.'.        .  .           0 

1.0 

0 

0 

41 

66 

749 

0 

38  .  3 

310 


T RE AT M E NT 


Simmons  College,  was  kind  enough  to  \vrite  out  the  interesting 
menus  for  severe  cases  of  diabetes  recorded  on  page  535.  This 
case,  as  well  as  Case  Xo.  1S1,  encouraged  me  to  persist  in  alternate 
fasting  and  feeding.  The  technic  of  treatment  was  far  better 
with  Case  Xo.  110C>.  I  Us  state  at  entrance  was  far  more  serious 
and  without  the  experience  acquired  with  other  cases  coupled  with 
other  advances  in  treatment,  so  far  as  the  Deaconess  Hospital  is 
concerned,  he  would  not  be  alive  today. 


TABLE  140.- 


-IXTERMITTEXT  FASTING.     CASK  Xo.  1267.     ONSET  AT  38  YEARS. 
TREATMENT  AT  43  YEARS. 


Date, 

1917. 

Urine. 

Diet  in  gnims. 

Carb. 
bal- 
ance. 

Blood 
sugar, 
per 

rent. 

Alveolar 
air  CO2, 
mm.  Ilg. 

T   i            Di-       x 

-:•  isr  * 

I 

Us,   Sugar 

us.      t-'nis. 

Carb. 

Prot. 

Fat. 

Aleli. 

Cal. 

Mar.  19-20 

I  MM)     +  +  + 

59 

— 

— 

— 

— 

— 

_ 

20-2  1 

IMK)     -f  +  +    2.2       52 

50 

8 

0 

0 

232 

_2 

0  .  29 

20 

21—22 

1000     +  +  +     1 

.  7      32 

30 

8 

0         0 

152 

•> 

26 

22-23 

2100 

+  + 

—           1  (i 

15 

8 

0         0 

92 

-1 

0  .  23 

25 

23-24 

1300 

+         1 

.  9         5 

0 

0 

00           0 

—  5 

27 

24-25 

1  100 

+ 

0 

0 

0 

0 

0           0 

0 

25-20 

1100 

+ 

4 

0 

35 

10 

0       230 

1 

20-  27 

1700 

+         2 

.2         9 

0 

35 

10 

0    :  230 

-9 

27-2,s 

1000     SI.   + 

1 

0 

0 

0 

0           0 

-1 

0.22 

2s  2'.) 

!)()()         + 

0 

0 

0 

0         0          0 

0 

29-30 

2100   '  SI.   + 

0 

0 

.'50         0         0 

120 

0 

30-31 

1700     SI.   + 

3 

0 

44       32         0 

4(54 

-3 

31-   1 

1500 

0 

0 

0 

0 

0  ;     o 

0 

0 

Apr.      1-  2 

1200 

si.  + 

0 

o 

34 

0  '      0 

190 

0 

2-  3 

2000 

0 

0 

0 

32 

20         0 

308 

0 

3-  4 

2500 

0         1 

.5         0 

0 

32 

38       2S       073 

0 

25 

4-  f) 

2000 

0 

0 

0 

38 

57  ;    2S       SO  I 

0 

0.1,  s 

5    n 

1800 

0 

0 

1 

45    i  03       28       947 

+1 

20-21 

2200 

0 

0 

3 

40 

79       2S     1103 

+3 

21-22 

2100 

0 

0 

r> 

47 

79       28     1115 

+5 

22-23 

2100 

0 

0 

6 

47 

77 

28     1101 

+G 

2:-!   24 

2000 

0 

0 

7 

48 

88 

19     1155 

+7 

24-25 

2100 

0 

0 

8 

48 

88 

0     1124 

+8 

25-20 

2200 

0 

0 

10 

49      ss 

0     109S 

+  10 

20-27 

2500 

0 

0 

0 

31       57 

0       001 

+0 

0.13 

Weight  March  19,  1917,  117  pounds;  weight  April  27,  1917,  110J  pounds. 

Intermittent  fasting  not  only  makes  the  treatment  less  arduous 
and  decidedly  pleasantrr  for  the  patient,  but,  it  gives  less  cause  for 
anxiety.  The  circumstances  which  suggest  themselves  at  first 
thought  as  favoring  an  alternation  of  fasting  and  feeding  periods 
are:  the  avoidance  of  loss  of  weight  and  loss  of  body  protein,  and 
the  prevention  of  acidosis.  These  topics,  ho\vever,  are  of  such 
broad  scope  that  they  \\ill  be  considered  following  the  remarks 
upon  the  details  of  treatment. 


DIETETIC   TREATMENT  317 

((/)  Determination  of  Tolerance  for  Carbohydrate. — When  the 
twenty-four-hour  quantity  of  urine  is  sugar-free,  one  can  usually 
give  a  few  grams  of  carbohydrate  to  the  patient  without  the  appear- 
ance of  glycosuria.  The  carbohydrate  is  generally  given  in  the 
from  of  5  per  cent,  vegetables,  choosing  those  which  are  especially 
bulky.  A  plateful  of  lettuce  appeals  much  more  to  the  patient 
than  a  small  saucer  of  string  beans.  When  a  mixture  of  5  per 
cent,  vegetables  is  given,  one  can  be  quite  sure  that  the  average 
content  of  carbohydrate  is  not  more  than  3  per  cent.1  or  approxi- 
mately 5  grams  for  the  150  grams  prescribed,  and  for  convenience 
this  is  reckoned  as  1  gram  of  carbohydrate  for  each  30  grams  Cl 
ounce).  This  small  amount  of  food,  of  course,  has  little  nutritive 
value,  but  is  enough  to  break  the  fast.  Upon  succeeding  days  5, 
10  or  even  more  grams  of  carbohydrate,  varying  with  the  severity 
of  the  case,  are  added  daily  until  sugar  returns  or  the  approximate 
quantity  is  reached  which  it  appears  probable  the  patient  will 
tolerate.  It  should  be  borne  in  mind  that  a  patient  fasting  or  on  a 
very  low  diet  often  shows  an  apparent  tolerance  for  carbohydrate 
far  in  excess  of  that  which  he  would  have  shown  if  the  necessary 
protein  and  fat  in  his  diet  were  simultaneously  ingested. 

A  carbohydrate  tolerance  test,  like  a  levulose  test,  often  destroys 
the  morale  of  the  patient.  He  cannot  understand  why  he  can  take 
so  much  at  one  time  and  so  little  at  another.  Therefore  I  believe 
it  more  practicable  to  work  up  to  about  the  carbohydrate  value 
which  appears  correct  rather  than  to  go  to  the  very  limit  of  tolerance. 

Following  the  trial  with  5  per  cent,  vegetables,  one  can  proceed 
to  the  10  per  cent,  group,  and  these  can  be  empirically  reckoned  as 
containing  0  per  cent,  carbohydrate  or  approximately  twice  that 
of  the  5  per  cent,  group,  or  5  grams  carbohydrate  for  75  grams 
vegetables.  From  this  point  onward  the  addition  of  carbohydrate 
can  be  made  according  to  the  desire  of  the  patient. 

Half  a  small  grapefruit  contains  about  10  grams  carbohydrate,  and 
half  a  dozen  oysters  4  grams,  and  they  make  welcome  additions. 
A  portion  of  carbohydrate  can  be  given  in  the  form  of  cream,  but 
I  do  not  like  to  allow  much  cream  or  other  attractive  food  contain- 
ing carbohydrate  until  it  is  evident  that  the  patient  will  be  able  to 
take  it  permanently.  For  this  reason  it  is  often  best  to  gradually 
replace  a  large  portion  of  the  5  per  cent,  vegetables  with  10  per 
cent,  vegetables  in  order  to  get  additional  carbohydrate,  and  if 
these  are  borne,  continue  to  add  carbohydrate  as  cream,  fruit  in 
the  form  of  grapefruit,  strawberries,  or  orange,  until  a  small  portion 
of  fruit  is  allowed  twice  a  day,  and  then  to  progress  to  peas  in  the 
15  per  cent,  group.  A  good  many  patients  can  take  potato  and 

1  See  p.  260. 


318  TREATMENT 

oatmeal.  Ten  grams  <.£  oatmeal  give  considerable  satisfaction  and 
contain  but  (i  grams  carbohydrate,  and  the  same  is  true  of  oO  grams 
of  potato.  One  seldom  allows  the  patient  to  increase  the  carbo- 
hydrate above  )•>  grams  per  kilo  body  weight,  even  if  it  is  borne, 
unless  he  remains  under  observation  or  can  be  thoroughly  trusted 
to  control  further  additions  by  the  Benedict  test. 

Indeed,  most  patients  with  mild  diabetes  feel  better  restricting 
the  quantity  of  carbohydrate  than  eating  freely  of  it.  A  few  cases 
can  bear  more,  but  until  the  urine  has  remained  sugar-free  for  three 
months,  it  is  best  not  to  attempt  an  increase.  On  the  other  hand, 
the  carbohydrate  should  not  be  kept  too  low.  Is  there  not  a  possi- 
bility that  if  one  restricts  the  carbohydrate  for  a  long  period  of  time, 
there  may  be  a  loss  in  power  to  utilize  it  simply  because  those 
functions  of  the  body  which  are  concerned  in  its  digestion  and 
assimilation  have  not  been  kept  continually  in  training?  The  more 
carbohydrate  a  diabetic  patient  can  take  without  glycosuria  the 
more  likelihood  there  is  of  increasing  the  carbohydrate  tolerance 
still  further.  It  looks  as  if  it  were  worth  while  to  sacrifice  almost 
anything  to  secure  a  tolerance  for  carbohydrate;  with  this  once 
attained,  strength  and  weight  follow  as  a  matter  of  course. 

With  children  one  often  makes  the  mistake  of  increasing  the 
carbohydrate  too  rapidly,  forgetting  the  fact  that  .">  grains  of  carbo- 
hydrate to  a  child  weighing  20  kilograms  is  in  the  same  proportion 
as  1")  grams  of  carbohydrate  to  an  individual  of  GO  kilograms. 

(c)  Determination  of  Tolerance  for  Protein. — So  soon  as  the  urine 
has  been  sugar-free  for  two  days,  about  -(}  grams  of  protein  are 
added  to  the  diet,  and  thereafter  lo  grams  of  protein  daily  until 
the  patient  is  receiving  1  gram  per  kilogram  body  weight.  The 
protein  may  be  given  either  in  the  form  of  fish,  lean  meat  or  eggs. 
Thirty  grains  of  fish  or  an  egg  of  average  size  contain  approx- 
imately G  grains  of  protein,  and  ))()  grams  of  lean  meat  contain 
approximately  X  grams.  The  white  of  an  egg  contains  '.}  grains  of 
protein.  By  this  arrangement  a  patient  weighing  GO  kilograms 
would  be  taking,  within  six  days  from  the  time  he  became  sugar- 
free,  1  gram  of  protein  per  kilogram  body  weight.  This  quantity 
is  quite  satisfying  to  all  except  children  in  fact,  it  astonishes  me  to 
find  how  few  patients  care  to  take  as  much  as  1  ..">  grams  of  protein  per 
kilogram  body  weight.  Children,  however,  crave  and  need  consider- 
ably more,  and  indeed  take  with  avidity  as  much  as  '2  or  M  grams 
protein  per  kilogram  body  weight. 

Fish  is  especially  desirable  in  the  early  days  of  protein  feeding 
because  it  contains  so  little  fat.  Cod,  haddock  and  flounder,  for 
example,  contain  less  than  1  per  cent. 

The  advantage  of  giving  and  increasing  protein  simultaneously 
with  the  determination  of  the  carbohvdrate  tolerance  is  that  one 


DIETETIC   TREATMENT  319 

approaches  more  nearly  normal  conditions.  What  the  physician  is 
after  is  to  determine  the  carbohydrate  tolerance  while  the  patient 
is  on  a  full  diet,  and  not  the  tolerance  for  carbohydrate  alone.  One 
must  not  forget  Klemperer's  observation  of  the  fasting  diabetic 
who  could  consume  nearly  100  grams  of  glucose  with  little  or  trifling 
glycosuria,  or  Benedict's  and  my  cases,  who  have  taken  a  gram  and 
a  half  of  levulose  per  kilogram  body  weight,  fasting,  and  excreted 
less  than  5  grams  of  glucose  during  the  same  twenty-four  hours. 
A  determination  of  tolerance  for  carbohydrate  of  that  type  is  of 
little  practical  value,  and  indeed  is  misleading.  On  the  other  hand, 
1  freely  admit  that  a  higher  carbohydrate  tolerance  can  be  attained 
when  the  addition  of  protein  following  the  preliminary  fasting  is 
deferred  until  the  actual  carbohydrate  tolerance  is  learned  in  the 
absence  of  protein  and  fat.  Naturally  the  method  adopted  will 
vary  somewhat  with  each  patient. 

There  are  very  few  patients  who  will  not  bear  at  the  outset  as 
much  as  1  gram  of  protein  per  kilogram  body  weight,  and  I  am  very 
loath  to  allow  the  protein  to  remain  permanently  below  this  figure. 
This  can  be  avoided  by  still  further  restricting  the  carbohydrate, 
either  temporarily  or  permanently.  It  is  always  necessary  to  bear 
in  mind  that  one  food  which  the  diabetic  patient  cannot  do  without 
is  protein,  and  to  it  everything  else  must  be  subordinated.  More 
and  more  I  believe  we  will  strive  to  spare  body  protein. 

Whether  it  is  desirable  for  diabetic  patients  to  take  more  than 
1  gram  of  protein  per  kilogram  body  weight,  /.  e.,  the  Chittenden 
standard,  is  still  unsettled.  The  120  grams  of  protein  which  the 
Voit  standard  places  as  normal  for  a  man  of  70  kilos  would  be  reduced 
to  100  grams  (actually  103)  protein  for  an  individual  of  60  kilos 
body  weight.  A  protein  intake  of  100  grams  is  a  trifle  higher  than 
what  Cannon  found  for  a  group  of  students  at  the  Harvard  Medical 
School,  but  is  the  protein  figure  now  usually  recognized  as  the 
American  standard.  It  would  seem,  therefore,  that  as  much  as  this 
quantity  of  protein  should  be  allowed  the  diabetic  whose  diet  is  so 
much  curtailed,  and  this  would  raise  up  to  1.5  grams  the  amount 
of  protein  allowed  per  kilogram  body  weight.  But  I  would  rather 
reduce  the  protein  from  100  to  75  grams  if  thereby  I  could  raise  the 
carbohydrate  from  15  to  a  total  of  40  or  even  o()  grains.  In  our 
radical  rearrangement  of  the  diet,  we  must  take  care  not  to  give  the 
patient  too  little  food.  A  normal  individual  has  his  instinct  and 
taste  to  control  the  quantity  of  his  diet,  and  it  is  a  serious  matter  to 
attempt  to  replace  such  controls  of  nature  with  arbitrary  rules. 

Low  quantities  of  protein  suffice  for  nephritic  patients  for  periods 
extending  over  many  years.  If  nephritic  complications  are  present 
with  the  diabetic,  one  is  therefore  justified  in  prescribing  a  low 
protein  diet.  Except  for  patients  of  this  character,  I  do  not  recall 


320  TREATMENT 

any  diabetic  patient  who  has  been  obliged  to  live  permanently  ou 
a  protein  intake  of  less  than  1  gram  per  kilogram  body  weight. 

(/)  Determination  of  Tolerance  for  Fat. — A  satisfactory  test  fo: 
the  tolerance  of  fat  by  a  diabetic  patient  as  yet  is  not  available. 
I  am  in  hopes  that  the  work  of  Professor  Bloor  and  Dr.  Gray  here 
and  that  at  various  other  laboratories  will  soon  give  us  some  indi- 
cation. At  the  annual  meeting  of  the  American  Medical  Association 
this  year  Bloor,  (tray  and  I  plan  to  present  a  summary  of  work  in 
this  direction,  based  upon  my  patients.  For  the  time  being  we  are 
compelled  to  fall  b::ck  upon  indirect  methods,  of  which  there  are 
two:  signs  of  acidosis  and  glycosuria.  So  long  as  these  exist  tin 
fat  must  be  kept  low.  \Miile  testing  the  protein  tolerance  a  small 
quantity  of  fat  is  included  if,  in  addition  to  whites  of  eggs  and  lean 
fish,  meat  is  given.  Formerly  I  thought  this  advantageous,  and  such 
small  quantities  of  fat  certainly  do  no  harm  in  the  milder  cases.  In 
fact,  the  same  rule  holds  for  the  testing  of  the  carbohydrate  and 
protein  tolerance  in  the  presence  of  fat  as  has  been  said  f<xr  protein 
alone.  There  are,  on  the  other  hand,  two  important  reasons  win- 
fat  should  not  be  given  to  the  diabetic  patient  immediately  upon  his 
becoming  sugar-free:  (1)  by  the  omission  of  fat  partial  fasting  is 
continued  and  thereby  the  patient  is  gaining  a  tolerance  for  carbo- 
hydrate, and  (12)  the  continued  omission  of  fat  is  beneficial  in  counter- 
acting the  last  vestige  of  acid  poisoning,  or  preventing  the  appear- 
ance of  acid  poisoning,  which  might  easily  occur  in  a  diabetic  patient 
whose  metabolism  has  not  become  accustomed  to  so  low  a  quantity 
of  carbohydrate.  But  so  soon  ;.s  the  patient  has  received  the  essential 
gram  of  protein  per  kilogram  body  weight,  the  fat  in  the  diet  should 
be  increased.  Ii'  the  patient  is  one  in  whom  acidosis  has  been  an 
essential  factor,  or  if  the  patient  is  obese,  the  fat  should  be  increased 
slowly,  and  for  such  a  patient  an  increase  of  ")  to  10  grams  a  day 
may  be  all  that,  he  can  take  without  the  recurrence  of  a  positive 
ferric  chloride  reaction  in  the  urine.  On  the  other  hand,  attention 
is  called  to  Case  Xo.  7o.~>,  p.  .'514,  who  after  persistent  periods  of 
intermittent  fasting  became  sugar-  and  acid-free,  and  yet  the 
immediate  addition  of  .'50  grams  fat  per  day  failed  to  cause  the 
reappearance  of  acidosis.  I  consider  the  cr.se  exceptional  in  this 
regard,  and  can  only  explain  it  by  the  fact  that  for  over  a  year, 
except,  for  temporary  periods,  the  diet  had  been  low  in  carbohydrate 
and  that  she  had  become  accustomed  to  considerably  larger  quantities 
of  fat  than  would  have  been  the  case  with  an  individual  whose  diet 
was  suddenly  changed.  ( 'ases  Nos.  liM.'!  and  \'2'.V.\  should  be  cited, 
who,  though  having  a  carbohydrate  tolerance  of  less  than  10  grains, 
took  respectively  00  and  7.~>  grams  levulose  and  00  and  7.~i  grams 
olive  oil  in  the  absence  of  protein  wit  IK  nit  t  he  appearance  of  acidosis 
or  of  more  than  1  gram  sugar  in  the  urine.  Cases  which  have 


DIETETIC   TREAT  ME  XT  321 

shown  little  acidosis  may  easily  he  allowed  an  increase  of  25  grams 
fat  daily,  and  for  such  cases  this  is  desirable  because  it  rapidly  brings 
the  total  caloric  value  of  the  diet  up  to  a  normal  figure.  Naturally, 
patients  in  whose  treatment  a  loss  of  weight  is  desired  would  ho 
given  smaller  quantities  of  fat.  How  inadequate  our  measures  of 
fat  tolerance  are  is  occasionally  shown  by  a  patient  like  Case  Xo. 
1228,  whose  acidosis  disappeared  as  fat  was  increased. 

(g)  The  Caloric  Needs  of  the  Patient. — The  total  number  of 
calories  which  a  diabetic  requires  varies  not  only  with  each  case, 
hut  varies  with  each  case  each  day.  Schematic  rules  do  not  hold. 
One  must  remember  that  an  individual  trained  to  he  quiet  and 
lying  down  can  get  along  with  only  20  calories  per  kilogram  body 
weight  reckoned  per  twenty-four  hours,  at  the  Nutrition  Laboratory 
whereas  the  average  of  a  large  group  of  normal  men  and  women, 
not  especially  trained  for  the  test,  consumed  25  calories  per 
kilogram  body  weight  reckoned  also  per  twenty-four  hours.1  If 
this  variation  exists  while  at  rest,  how  much  more  it  must  exist 
during  the  various  activities  of  different  individuals.  Furthermore, 
one  must  remember  that  the  number  of  calories  consumed  per  hour 
varies  enormously.  During  sleep,  Benedict's  fasting  man  burned 
1  calorie  per  kilogram  body  weight  per  hour  the  day  before  the 
beginning  of  the  experiment,  while  during  the  daytime  and  awake 
although  still  at  rest,  the  number  of  calories  rose  to  1.05.  During 
the  fast  while  asleep  the  metabolism  on  the  same  basis  dropped  to 
O.S5  calorie,  and  when  awake  to  0.05  calorie.  In  the  previous 
section  it  has  been  pointed  out  that  an  individual  weighing  GO 
kilos  walking  at  the  rate  of  four  miles  per  hour  would  require 
an  additional  19.'}  calories  for  that  hour  over  the  resting  metab- 
olism. Habits  of  individuals  vary  widely.  Some  are  quiet 
"and  some  are  active.  All  these  considerations  should  be  clearly 
borne  in  mind  by  doctors  and  patients  in  order  not  to  allow  them- 
selves to  be  held  too  rigidly  by  any  caloric  fetish.  Patients  coming 
for  treatment  with  severe  acidosis  consume  from  10  to  20  per  cent, 
more  calories  per  kilogram  body  weight  than  patients  after  they 
have  become  sugar-free  and  free  from  acid.  One  of  the  most 
interesting  cases  of  this  group  is  that  of  Case  No.  7(>5,  p.  314.  This 
topic  has  been  discussed  in  detail  in  the  section  on  Metabolism, 
and  a  forthcoming  monograph  by  Benedict  and  myself  will  appear 
as  a  Carnegie  Publication.  After  the  diabetic  has  become  sugar- 
and  acid-free,  he  apparently  gets  along,  as  Naunyn  long  ago  pointed 
out,  with  a  smaller  amount  of  food  than  an  ordinary  individual. 

1  The  error  should  not  be  made  of  concluding  that  an  energy  loss  of  25   calories, 

per  kilcgram  body  weight  in  the  fasting  state  can  be  replaced  by  a  diet  with  the 

corresponding  number  of  calories.       In  reality  a  considerably  greater  number  of 

calories,  would  be  required,  due  to  the  specific  dynamic  action  of  the  food  ingested. 

21 


322  TREATMENT 

This  may  be  so.  From  a  study  of  dietary  charts  in  diabetes,  it 
appears  probable,  but  1  do  not  believe  the  question  yet  settled. 
Before  this  can  be  done,  studies  should  be  made  upon  cases  of 
diabetes  of  the  severest  type  who  have  become  sugar-  and  acid-free 
and  remained  so  for  a  period  of  weeks.  The  caloric  values  of  their 
diets  should  then  be  quantitatively  determined.  Ordinary  calcula- 
tions, ba^ed  on  dietary  tables,  will  not  suffice.  Actual  analyses  of 
the  diets  of  a  group  of  such  patients  for  a  period  of  several  weeks 
should  be  made.  This  is  by  no  means  an  impracticable  matter, 
and  I  think  the  accomplishment  of  it  would  be  of  the  greatest  help 
to  diabetic  patients  and  would  settle  many  mooted  points. 

(1)  Lout  Caloric*. — When  Dr.  Benedict  and  1  recently  compared 
the  actual  metabolism  of  diabetic  patients,  as  determined  by  the  Car- 
negie Respiration  Chamber,  with  the  calculated  calories  of  the  diet, 
it  was  perfectly  plain  that  errors  in  the  dietetic  calculations  must 
exist,  and  that  the  patients  must  be  receiving  far  more  food  than 
was  supposed.  A  search  was  immediately  instituted  for  these  lost 
calories.  Very  fe\v  calories  could  escape  notice  in  the  form  of 
carbohydrate,  because  the  patients  did  not  receive  carbohydrate. 
Only  a  few  calories  could  escape  notice  in  the  form  of  protein, 
because  our  calculations  have  shown  that  the  nitrogen  excretion 
and  the  calculated  nitrogen  content  of  the  food  were  consistent. 
rl  he  only  essential  error  I  found  in  the  protein  calculation  was  in 
the  case  of  one  patient  who  was  taking  10  grains  in  the  form  of 
gelatin  each  day  instead  of  the  customary  '2  or  .'>  grams,  which 
patients  not  upon  a  fasting  diet  frequently  receive  without  record 
in  the  dietetic  calculations.  The  protein  in  broths  is  not  so  easily 
disregarded,  particularly  in  the  case  of  young  children,  for  whom  a 
few  grams  of  protein  count  much.  By  exclusion,  therefore,  the  lost 
calories  must  exist  in  the  form  of  fat.  In  previous  dietetic  deter- 
minations, the  quantity  of  fat  in  an  egg  had  been  reckoned  at  o 
grams,  but  probably  (>  grains  is  a  more  correct  figure  and  the  one 
we  now  adopt,  and  if  the  eggs  are  large  the  figure  would  rise  still 
higher.  It  seems  probable  that  upon  a  diet  containing  three  eggs 
a  patient  received  :>()  calories  more  than  previously  supposed. 
Similarly,  with  fat  in  the  meat,  actual  analyses  showed  that  even  a 
mixture  of  lean  meat,  as  served  by  nurses,  sometimes  contains 
approximately  !•">  per  cent,  of  fat,  and  as  most  of  the  patients  were 
receiving  from  100  to  l.">0  grains  of  meat,  -!.">  to  70 calorics  would  be 
gained  in  t  his  manner.  These  errors  have  been  in  a  measure  obviated 
for  this  last  year  by  the  correction  of  the  values  assigned  to  foods 
on  the  dietary  charts.  The  fads  are  mentioned  simply  to  show  that 
patients  very  likely  receive  more  calories  than  lias  been  supposed, 
and  illustrate  the  necessity  of  accurate  analyses  of  the  total  diets  of 
diabetic  patients  before  any  statements  have  been  made  about  the 
total  quantity  of  calories  which  they  require.  For  the  present 


DIETETIC   TREATMENT  323 

the  physician  must  to  a  large  extent  be  guided  by  the  appearance 
and  weight  of  his  patient  and  the  condition  of  the  urine  while 
attempting  to  regulate  the  calories  allowed. 

Should  the  calories  be  raised  above  a  minimum  portion  in  severe 
cases  of  diabetes,  glycosuria  will  return.  Therefore  great  care 
must  be  taken  to  prevent  overeating.  This  is  not  the  only  danger. 
If  the  carbohydrate  tolerance  is  lo\v  and  fat  is  too  rapidly  increased, 
acidosis  and  death  follow.  Hence  the  need  for  supervision  after  the 
patient  has  left  the  hospital.  More  deaths  in  diabetes  must  be 
attributed  to  this  cause  than  to  any  other. 

(/?)  Reappearance  of  Sugar. — The  return  of  sugar  demands  fasting 
for  twenty-four  hours,  or  until  sugar-free.  This  rule  should  be 
inflexibly  followed,  especially  with  children.  In  hospitals  it  simpli- 
fies the  treatment  enormously.  So  soon  as  it  is  understood  that 
the  reappearance  of  sugar  means  a  fast  until  glycosuria  disappears 
from  the  twenty-four-hour  quantity  of  urine,  there  is  little  tendency 
to  break  over  the  diet.  Furthermore,  most  patients  are  thrifty 
enough  to  see  the  disadvantage  of  paying  their  board  with  no  return. 
The  rule  must  be  rigidly  enforced  with  children,  because  with  them 
disobedience  means  death.  When  a  patient  has  been  made  sugar- 
free  by  a  preliminary  fast,  absence  of  food  for  twenty-four  hours 
will  almost  invariably  be  sufficient  to  free  the  urine  at  once  if  the 
sugar  returns.  This  will  not  be  the  case  unless  the  presence  of 
glucose  is  promptly  detected,  and  hence  the  necessity  for  the  patient 
t  >  examine  his  twenty-four-hour  urine  daily.  Following  this 
accessory  fasting  day,  the  previous  diet  of  the  patient  may  be 
gradually  resumed,  making  every  endeavor  to  regain  the  former 
tolerance  for  carbohydrate  by  slowly  increasing  the  quantity  of 
fat.  (ireat  care  should  be  exercised,  more  indeed  than  I  have  often 
taken,  not  to  break  down  the  tolerance  a  second  time.  No  heavier 
burden  in  this  regard  should  be  laid  upon  the  patient  than  he  can 
easily  bear.  Months  rather  than  weeks  should  intervene  before 
the  final  amounts  of  carbohydrate,  protein  and  fat  reached  the 
second  time,  equal  the  quantity  of  carbohydrate  taken  when 
sugar  reappeared.  I  have  always  been  much  impressed  by  the 
success  of  Drs.  Janeway  and  Mosenthal  in  the  treatment  of  one  of 
their  patients,  because  the  patient  had  been  taught  to  keep  the 
carbohydrate  so  low  that  sugar  did  not  reappear,  though  he  was 
away  from  their  supervision  for  a  period  of  months. 

(/)  Weekly  Fast  Days. — The  advantage  which  the  older  clinician 
derived  from  the  use  of  one  day's  fast  in  seven  in  the  treatment  of 
his  diabetic  patients  should  ever  be  borne  in  mind.  Case  Xo. 
1002,  now  under  observation,  who  contracted  diabetes  twenty-six 
years  ago,  possibly  in  connection  with  gall-stones,  tells  me  that 
at  that  period  her  physician,  Dr.  Randall,  of  Topsh'eld,  Mass.. 
often  told  her  to  go  without  food  save  broths  for  several  days  in 


324  TREATMENT 

succession,  and  that  she  would  follow  this  advice.  Her  severe 
symptoms  of  diabetes  subsided  at  the  end  of  four  years.  Recently 
the  quantity  of  sugar  has  been  slight.  Her  tolerance  on  June  1, 
1010,  reached  11(>  grains  carbohydrate.  One  striking  characteristic 
of  Dr.  Allen's  helpful  suggestions  in  the  treatment  of  diabetes  has 
been  that  he  has  apparently  sought  out  every  method  which  anyone 
has  found  useful  in  the  treatment  of  diabetes,  tested  its  worth,  and 
endeavored  to  adapt  it  to  modern  conditions.  The  advantage  of 
this  restricted  diet  day  each  week  is  partly  inherent  in  the  fast  or 
restricted  diet,  but  to  a  considerable  extent  it  is  due  to  the  attention 
of  the  patient  being  sharply  called  t;>  his  disease  one  day  in  seven, 
and  the  recollection  which  it  awakens  in  his  mind  of  his  condition 
before  treatment  began  and  the  difficulties  which  originally  accom- 
panied becoming  sugar-free. 

Any  patient  with  a  tolerance  for  less  than  20  grams  carbohydrate 
should  fast  one  day  in  seven;  when  the  tolerance  is  above  20  grains 
carbohydrate,  upon  the  weekly  fast  day  halve  the  calories. 

Some  exceptions  to  the  above  rules  may  be  mentioned;  for 
example,  elderly  patients  bear  fasting  poorly,  and  when  they 
remain  sugar-free  upon  a  rigid  diet  containing  only  10  grams  of 
carbohydrate,  it  is  my  impression  that  it  is  better  to  simply  restrict 
the  calories  of  the  diet  one-half  on  one  day  each  week  rather  than  to 
institute  an  absolute  fast.  Children  become  fretful  upon  a  fast  day, 
but  if  they  are  allowed  a  few  green  vegetables  in  addition  to  broths, 
they  get  along  very  well  indeed.  Yon  Xoorden  pointed  out  that  the 
good  effects  of  a  fast  day  continued  many  days  beyond  the  actual 
fast. 

Several  of  my  severest  cases,  whose  metabolism  has  been  jointly 
studied  with  the  stall'  of  the  Nutrition  Laboratory,  were  able  to 
take  upon  their  weekly  fasting  day  (>()  to  7f>  grams  levulose  and 
equal  quantities  of  olive  oil  with  the  result  that  the  sugar  in  the 
blood  on  the  following  morning  was  the  same  or  lower  than  before 
the  above  were  given,  and  the  total  quantity  of  sugar  in  the  urine 
during  the  corresponding  twenty-four  hours  less  than  1  gram. 
Consider  what  this  would  mean  to  diabetic  patients  if  it  would 
hold  true  in  every  case.  The  7SO  and  (.)7.">  calories  thereby  saved  each 
week  would  amount  to  a  gain  of  between  40,000  and  .">(), 000  calories 
in  the  course  of  one  year.  (See  p.  37X.) 

").  The  Management  of  Mild  Cases  of  Diabetes. — The  mild 
case  of  diabetes  is  the  case  which  demands  the  most  energetic 
treatment,  but  hitherto  has  received  the  least.  These  cases  are 
analogous  to  the  cases  of  incipient  tuberculosis.  As  in  tuberculosis, 
a  "cure"  may  not  be  effected,  but  the  disease  is  held  in  check. 
Emphasis  should  be  placed  on  freedom  from  glycosuria.  Xaunyn's 
dictum  that  "many  a  severe  case  was  originally  mild,  but  neg- 
lected," should  not  be  forgotten, 


DIETETIC   TREATMENT  325 

These  patients  should  be  taught  to  take  long  vacations,  secure 
an  abundance  of  sleep,  avoid  excess  in  mental  and  physical  labor, 
shun  obesity,  and  provide  for  daily  exercise.  It  is  best  to  be  frank 
with  such  patients,  and  warn  them  of  the  danger  of  neglecting 
treatment. 

It  is  not  necessary  for  such  patients  to  practise  fasting.  Formerly 
the  reduction  of  carbohydrates  to  100  grams  would  often  suffice 
to  stop  the  glycosuria.  In  our  enthusiasm  for  new  methods  it  should 
not  be  forgotten  that  even  in  the  past  good  results  were  obtained 
with  the  majority  of  diabetics,  and  that  gradual  restriction  of 
carbohydrate  was  the  means  employed.  Incidentally,  this  is  good 
proof  that  most  diabetics  are  not  severe.  The  simple  omission  of 
fat  will  lead  to  a  great  reduction  in  the  sugar  excreted,  which  will 
be  accentuated  if  the  protein  is  limited  to  a  gram  and  a  half  per 
kilogram  body  weight.  Combined  with  the  above  the  exclusion 
of  actual  sugar  from  the  dietary  and  the  substitution  of  potato 
(20  per  cent,  carbohydrate)  for  bread  (GO  per  cent,  carbohydrate) 
will  frequently  secure  a  sugar-free  urine.  It  is  onerous  for  a  patient 
to  eat  100  grams  starch  in  the  form  of  potato,  but  enjoyable  to 
consume  it  as  bread.  Later,  fat  is  added  as  needed  to  maintain  a 
suitable  weight.  This  method  of  treatment  is  very  successful  with 
my  good-natured  and  usually  obedient,  fat  doctor-patients. 

The  milder  cases  of  diabetes  in  a  few  weeks  attain  a  tolerance  of 
more  than  100  grams  carbohydrates.  Such  cases  should  limit 
the  quantity  of  carbohydrates  in  their  diet  for  years,  even  though 
no  signs  of  sugar  appear.  It  is  interesting  to  note  that  many  of  these 
patients  like  Case  No.  1287  feel  better  and  have  less  digestive 
trouble  if  the  quantity  of  carbohydrates  is  held  at  about  125 
grams  to  150  grams  even  though  they  tolerate  more.  Such  indi- 
viduals live  apparently  in  perfect  health,  and  there  is  always 
satisfaction  in  the  belief,  and  I  think  justification  for  it,  that  treat- 
ment has  prevented  the  progress  of  the  disease.  Mention  of  these 
cases  is  made  in  the  discussion  of  the  Cases  of  Fifteen  or  More 
Years'  Duration,  page  4(58. 

G.  The  Management  of  Severe  Cases  of  Diabetes. — It  would 
be  wrong  to  give  the  impression  that  the  treatment  of  severe  diabetes 
is  simple  and  free  from  anxiety.  It  is  true  that  it  is  much  simpler 
and  causes  infinitely  less  worry  to  the  physician  than  heretofore, 
but  these  patients  are  in  most  unstable  equilibrium  and  a  little 
upset  of  trivial  character  may  lead  to  much  danger.  The  physician 
who  treats  severe  diabetes  successfully  must  constantly  be  in  close 
touch  with  his  patient.  Forewarned,  forearmed.  I  would  rather 
have  one  glance  at  a  severe  case  of  diabetes  twice  or  possibly  three 
times  a  day  than  to  be  furnished  the  laboratory  report  of  any  test 
for  acidosis.  Of  course,  both  observation  and  report  should  go 
hand  in  hand  and  invariably  I  try  to  provide  for  both. 


320  THE  ATM  EXT 

Severe  eases  of  diabetes  cause  the  most  worry  at  the  beginning  of 
treatment.  A  gastrointestinal  upset,  a  careless  alteration  of  diet, 
anxiety,  excitement,  overexertion,  a  mild  intercurrent  disease  or 
an  infection  may  favor  the  outbreak  of  coma.  Yet  Case  No.  10.1 
went  through  a  severe  attack  of  mumps  at  the  height  of  his  severe 
diabetes  successfully;  Cases  Nos.  S,  It),  M,  4(i,  35S,  435,  895  and  1274 
survived  pneumonia,  Table  174,  and  Case  No.  SI  3  withstood  tonsil- 
litis. Nevertheless  it  remains  true  that  in  the  presence  of  an  infec- 
tion the  tolerance  for  carbohydrate  is  apt  to  suffer  and  unless 
precautionary  measures  are  taken  coma  may  supervene.  Case  No. 
705,  described  in  detail  under  Intermittent  Fasting  (page  413), 
entered  the  hospital  on  December  (>,  1915,  with  3..']  grams  of 
ammonia  in  the  first  twelve  hours.  Following  drainage  of  an  alveolar 
abscess,  which  had  made  its  way  deeply  into  the  jaw,  the  acidosis 
decreased  more  rapidly  than  would  have  been  expected  with  ordinary 
treatment.  A  somewhat  similar  experience  has  been  observed  with 
Case  No.  951,  who  had  pyorrhca.  The  severity  of  the  diabetes 
of  Case  No.  1239  greatly  decreased  when  an  abscess  of  his  lung  was 
drained  following  the  excision  of  portions  of  four  ribs.  (See  p.  443.) 
Therefore,  all  such  contingencies  should  be  avoided,  or  at  least 
anticipated.  It  is  because  1  have  seen  so  many  cases  of  this  kind 
in  the  past  die,  as  1  now  know  needlessly,  that  I  lay  so  much  stress 
upon  the  preparatory  treatment  of  such  patients  before  fasting, 
for  such  a  plan  of  procedure  will  tend  to  lessen  the  dangers  to  which 
these  cases  are  exposed  in  the  presence  of  any  emergency. 

For  these  severe  cases  a  trained  diabetic  nurse  permanently  in 
charge  of  the  patient,  is  of  the  greatest  assistance  to  the  patient  and 
family.  My  nurses  tell  me  that  it  is  seldom  wise  for  them  to  remain 
longer  than  three'  months  with  any  given  patient.  They  prefer 
to  trade  cases  with  their  friends  and  this  plan  works  out  happily 
for  all  concerned.  If  a  nurse  is  not  available,  success  in  treatment 
depends  upon  the  thorough  education  of  the  patient.  The  wise 
live  long;  the  ignorant  early  succumb.  Once  having  thoroughly 
mastered  the  essentials  of  treatment,  these  patients  need  little 
supervision.  They  manage  themselves  quite  well  and  frequently 
give  useful  suggestions  for  their  own  treatment  and  that,  of  others; 
1  can  truthfully  write  that  their  chance  for  improvement  is  dis- 
tinctly greater  today  than  one  year  ago. 

Case  No.  032,  p.  3*2,  has  faithfully  carried  out  treatment  and  his 
course  is  an  encouragement  to  all.  Case  No.  119(1,  described  in 
detail  on  page  .'579,  is  as  good  an  illustration  of  the  treatment  of  a 
severe  cast'  as  Dr.  Ilornor  and  I  have  had.  lie  was  later  put  under 
the  charge  of  Dr.  I>righam,  who  has  clinched  the  improvement 
gained. 

The  following  sentences  upon  the   behavior  of  severe  cases  of 


FOLLOW-UP  METHODS  327 

diabetes  were  written  by  me  before  the  introduction  of  fasting 
treatment,  but  the  essential  features  are  true  today.  "  I  have  never 
seen  a  diabetic  patient  do  well  who  had  wholly  given  up  diet,  and  1 
confess  that  I  have  had  considerable  opportunity  to  observe  such 
cases.  The  family,  the  friends,  the  patient,  and  the  doctor  will 
all  get  along  more  comfortably  if  the  diet  throughout  the  whole 
course  of  the  disease  is  kept  at  a  point  where,  in  the  first  place,  sugar 
remains  absent  from  the  urine  (but  failing  this,  at  a  point  so  strict 
that  any  greater  restriction  might  be  productive  of  coma).1  The 
attitude  of  the  patients  themselves  under  the  two  conditions  is 
very  different.  In  the  former,  we  have  the  weak,  complaining 
melancholic,  tearful  patient,  Avith  complications  of  the  nerves, 
eyes,  or  skin  almost  invariably  with  us.  With  the  strict,  dietetic 
treatment,  these  complications,  no  matter  what  their  original  cause, 
are  far  less  numerous,  and  I  have  frequently  been  impressed  by  the 
freedom  from  despondency  of  those  who  live  faithfully  by  it.  The 
urines  of  the  two  groups  of  patients  may  show  no  essential  differ- 
ence in  the  total  quantity  of  sugar,  and  the  urine  of  the  strictly 
dieted  case  may  show  more  acid;  yet  the  general  well-being  of  the 
strictly  dieted  patient  is  far  better  than  that  of  his  careless  brother." 

D.     FOLLOW-UP  METHODS. 

Almost  any  physician  can  get  his  diabetic  patients  sugar- free, 
but  to  keep  these  patients  sugar-free  and  in  good  health  is  an  art. 
A  doctor's  ambition  should  be  not  to  see  how  large  a  number  of 
diabetic  patients  he  can  have,  but  how  large  a  number  he  can  keep 
well.  The  education  of  the  patient  is  the  basis  for  success  along  this 
line,  and  this  must  begin  at  the  very  start.  Upon  finding  that  the 
mortality  among  my  patients  during  the  last  twelve  months  was 
largely  due  to  ignorance,  a  nurse  was  secured  to  help  in  remedying 
this  defect.  She  began  work  May  1,  with  five  months'  handicap 
on  this  statistical  year,  and  I  anticipate  much  from  her  efforts. 
Why  should  not  all  our  patients  have  the  advantage  of  social  service, 
such  as  Dr.  Brigham's  diabetics  in  the  Out-patient  Department  of 
the  Massachusetts  General  Hospital  enjoy?  Hospital  treatment 
should  be  beneficial,  if  for  this  reason  alone.  The  patient  comes  in 
close  contact  with  the  doctor,  his  questions  can  and  should  be 
answered,  and  he  has  an  opportunity  to  learn  how  to  live.  The 
presence  of  other  diabetics  in  the  hospital  is  also  salutary,  and  it 
does  no  harm  for  him  to  see  cases  far  more  severe  than  his  own, 
because  this  emphasizes  the  importance  of  early  treatment.  So 
far  as  is  known  today  it  is  possible  for  patients  to  keep  sugar-free 

1  Of  course  this  idea  is  now  recognized  as  incorrect. 


32S  TREATMENT 

and  maintain  strength  by  means  of  fasting  days  and  a  diet  with 
or  without  carbohydrate,  but  with  a  moderate  quantity  of  protein 
and  fat.  These  are  the  principles  which  must  be  instilled  into  the 
patient.  Patients  must  be  taught  from  the  first  that  the  preliminary 
treatment  represents  only  a  beginning  of  treatment;  that  treatment 
lasts  for  life;  that  whenever  sugar  or  acidosis  returns  or  unusual 
loss  of  weight  occurs  and  they  are  unable  to  control  these  phenomena, 
they  must  report  to  a  physician.  The  physician,  too,  must  do  every- 
tii'ng  in  his  power  to  keep  in  touch  with  his  patients  at  regular 
intervals.  Of  course,  this  is  quite  difficult  because  he  is  laid  open 
to  the  suspicion  of  seeking  practice;  but  it  is  better  to  run  the  chance 
of  a  misunderstanding  on  this  score  in  one  case  than  to  let  ten  other 
cases  perish.  One  of  the  (thief  advantages  of  modern  treatment  is 
that  it  is  less  costly  than  former  methods.  Frequently  all  visits 
and  all  urinary  examinations  are  avoided,  and  this  fact  itself  makes 
it  much  easier  for  the  physician  to  deal  with  his  patients. 

Doctors  who  have  patients  temporarily  under  their  care  in  hos- 
pitals o\ve  it  to  their  patients  to  keep  the  family  physician  in 
touch  with  the  method  of  treatment  employed.  Formerly  I  sent  a 
copy  of  the  chart  at  the  end  of  the  hospital  stay;  beginning  April  1, 
I  hope  to  send  weekly  reports,  written  out,  if  possible,  by  the 
patients  themselves.  For  this  purpose  the  type  of  chart  on  page  .'$()(> 
will  be  better  than  I  have  hitherto  used.  Once  I  sent  a  patient  with 
exophthalmic  goitre  to  the  Mayo  Clinic  and  received  four  unsolicited 
reports  upon  the  progress  of  her  successful  treatment. 

Only  too  often  by  former  methods,  and  1  am  forced  to  say  by 
methods  employed  by  me  so  recently  as  last  year,  a  patient  would  go 
down  hill  soon  after  leaving  the  hospital,  because  of  imperfect 
training  as  to  how  to  live  outside.  It  is  unquestionably  true  that 
when  glycosuria  is  abolished  and  strength  diminished  by  long- 
fasting,  and  then  glycosuria  and  acidosis  allowed  to  return  through 
improper  diet,  the  last  stage  of  that  patient  may  be-  worse  than  the 
first.  Two  methods  are  open  to  guard  against  this  eventuality: 
(1)  the  education  of  the  patient  in  the  treatment  of  diabetes,  and 
('2)  the  education  of  his  physician. 

E.     SUMMARIES  OF  THE  TREATMENT  EMPLOYED  IN  THREE 
SUCCESSIVE  GROUPS  OF  CASES. 

The  treatment  of  diabetes  is  changing  so  rapidly  that  it  is  diffi- 
cult to  grasp  its  essential  features  from  a  study  of  individual 
cases.  Consequently,  in  the  following  tables  1  have  endeavored 
to  summarize  the  treatment  of  three  groups  of  cases  of  diabetes, 
each  consisting  of  '50  cases,  seen  in  chronological  periods  during 
the  last  two  years.  (Tables  1-17,  1  IS  and  11!).)  For  the  sake  of 


SUMMARIES  OF  THE  TREATMENT  EMPLOYED         329 

comparison,  further  summaries  of  eaeli  of  the  three  tables  are  given 
in  Table  150. 

It  will  be  noted  that  in  the  tables  the  date  of  entrance  to  the 
hospital,  the  duration  of  the  stay,  the  weight  at  entrance,  the  lowest 
weight  reached,  and  the  weight  at  exit  are  given.  In  order  to 
simplify,  yet  show  the  general  plan  of  diet,  its  composition  during 
the  first  and  last  weeks  of  hospital  stay  is  given  and,  for  comparison 
between  the  patients,  calculated  per  kilogram  body  weight.  The 
duration  of  the  diabetes  gives  some  idea  of  the  character  of  the 
cases,  and  this  is  recorded  to  December  1,  1910,  and  by  noting  the 
date  of  entrance  it  is  an  easy  matter  to  learn  the  age  of  the  patient 
on  entering  the  hospital.  Finally,  the  preliminary  method  of  treat- 
ment is  indicated,  namely,  whether  it  commenced  with  fasting  or 
with  preparatory  treatment,  that  is,  diminution  of  fat  and  protein 
prior  to  the  fast,  though  often  by  this  plan  the  patients  became 
sugar-free  and  actual  fasting  was  not  used  at  all. 

In  the  last  three  columns  the  question  of  acidosis  is  considered. 
In  the  early  cases  but  few  showed  its  absence  throughout,  either 
developing  it  in  the  hospital  or  entering  with  it.  A  gratifying 
decrease  in  the  number  of  cases  who  developed  acidosis  is  evident. 

The  criteria  for  the  selection  of  cases  in  the  table  were  (1)  that  the 
patients  should  have  been  over  fifteen  years  of  age,  and  (2)  should 
have  remained  at  least  two  weeks  in  the  hospital.  All  cases  recorded 
in  these  tables  left  the  hospital  alive  except  case  No.  1)04,  who  died 
with  a  carbuncle.  Eleven  others  succumbed  within  eight  months 
of  discharge.  These  cases  are  indicated.  The  duration  of  the  fatal 
cases  is  recorded  to  date  of  death  instead  of  to  December  1,  1910. 
It  is  hoped  that  the  introduction  of  this  method  of  presenting  results 
of  treatment  will  prove  a  valuable  innovation  in  our  management  of 
diabetes.  Undertaken  with  little  conception  as  to  what  the  average 
results  would  be,  it  shows  quite  clearly  the  errors  in  the  past  and 
indicates  where  the  weak  places  in  modern  diabetic  treatment  lie. 

1.  Loss  of  Body  Weight. — Considerable  obscurity  exists  about  the 
changes  in  body  weight  which  take  place  in  fasting.  If  one  looks  at 
the  table  on  p.  150  for  the  healthy  man  who  fasted  for  thirty-one 
days  at  the  Nutrition  Laboratory,  he  is  struck  by  the  uninterrupted 
loss  of  weight  each  successive  day.  No  such  consistency  is  noted  in 
the  weights  of  diabetics  while  fasting.  Undoubtedly  this  is  in  some 
way  connected  with  the  salt  metabolism,  and  very  likely  is  related 
to  the  acidosis  as  well.  (See  pp.  129  and  130.)  At  any  rate,  a  gain 
in  weight  of  a  few  pounds,  so  far  as  the  patient's  symptoms  are 
concerned,  is  a  favorable  indication,  and  a  loss  of  weight  of  over  a 
few  pounds  is  distinctly  unfavorable.  It  is  wholesome  education  for 
the  diabetic  patient  during  fasting  to  see  that  gain  and  loss  of  weight 
are  in  no  way  related  to  his  previous  diet.  The  question  of  ~.'.^ht 


330 


TREATMENT 


•upjcuj 


SUMMARIES  OF  THE  TREATMENT  EMPLOYED         331 


U 


+  :  :  : 


H-  :++  :  : 


•UldJOJJ 


L"  S  ^  ~  O  •M 


rtOiNOOOOOOOOOOXOOOOOOOi 


—  -f  ^) "/:  c~.  o  —i  O  — <  t- 1-  cc 


^   S3 


g  •! 

Q'3| 

C"a  o 

~J:~ 

"  I         II 

c;    . 

ilil 

?i  R  fo  ?3  ri  ~5  re  —  —  —  o  ''-  '^  i-  -3  '-:  1~  ir  -j:  --D  x  f-  —  x  x  x 
OOOMOOOOOOOOOOOOOOOOO1>OSBOOO 

332 


TREATMENT 


:  +  + 


•  •  :  :  !- 


>~  v.  —  — .  — <  ~  T  — '  t^  ~  x  c;  •—  ~.  i^  'M  -1-  ~\  — •  -r  :^  f.  >~  '"  >—  c      re  -H  o  O 
i.~  -r  —  i-  x  '-•:  -—  t^  -r  -^  ^  'O  re  1.7  [^  c~.  -f  ^  -c  —  X  w  -*•  •—  ••  ^2      1.7 10 1.~  i» 


SUMMARIES  OF  THE  TREATMENT  EMPLOYED 


TABLE  150.—  SUMMARY  OF  TABLES  147,  14S  AND  149,  SHOWING  THE  TREATMENT  OF  THREE  GROUPS  OF  THIRTY  CASES 
EACH  OF  J)IAHKTER  A.I  SUCCESSIVE  I'EHIODS. 

| 

3^nK^r 

CO 

o 

71 

3 

o        ii 

US 

1 

ri 

£;     "S     d 
"     ^2  ^ 

- 

-f 

Cl 

Treatment 

begun  with 

_o  _.  a  'S    . 

X) 

s 

as 

"2  ^ 

a 

s 

c 

.5  £  t  -o 

X 

^ 

c 

-t 

2 

3 

s 

^ 

| 

.=      ^5 

2 

s 

CO 

"a         "3 
"c 

EH 

0 

1 

1 

•IoqoDIV 

*H 

•* 

CO 

"^ 

g 

X 

o 

'UIOJOJJ 

s 

0 

s 

•^-0^3 

J1 

5 

co 

| 

.-      -5 

•sH 

-, 

0 

c  ,    -s 

r" 

C-'l 

i 

US 

CO 

•loqoOIV 

C, 

- 

- 

W 

3 

- 

2 

•nt.noaj 

s 

c-'i 

C-l 

-oqjBj 

2 

0 

s 

Weight  in 

kilograms. 

•sso-j 

N 

X! 

o 

•»F3 

5 

§ 

3S 

•,So.tto-! 

s 

§ 

CO 

'OOUCJJUjJ 

g 

jr. 

s 

•p;}i(Jsoq  in  =.'Ci:p                     -,                             «- 
joqiunu  aSujOAy                                            ~' 

-x 

o 
"S 

1-     ~  -J 

!i4i 

>?a"r 

•dnoiQ 

- 

- 

a 

334  TREATMEXT 

changes  in  weight  therefore  need  cause  no  anxiety.  On  the  other 
hand,  they  obscure  the  picture,  and  it  is  difficult  to  tell  what  a 
patient's  actual  weight  is  as  a  result  of  fasting  until  he  has  been 
under  treatment  for  several  weeks,  for  of  course  these  rapid  changes 
in  weight  merely  represent  variations  in  the  water  balance  of  the 
body.  To  lose  even  200  grains  of  body  fat  1SOO  calories  must  be  set 
free.  Edema  occasionally  develops,  but  so  far  I  am  able  to  assure 
my  patients  that  I  have  seen  no  diabetic  patient  with  edema  develop 
coma,  and  have  seen  no  serious  result  from  edema.  This  can 
usually  be  dispelled  with  theocin  or  diuretin.  A  loss  of  weight 
in  an  emaciated  diabetic  should  only  be  tolerated  as  a  therapeutic 
necessity.  Once  lost  in  such  an  individual,  it  is  difficult,  but  by 
no  means  impossible,  to  regain.  (See  Case  Xo.  110(1,  p.  379.) 

The  mere  word  "fasting"  awakens  ideas  of  marked  loss  of  weight 
during  the  course  of  modern  diabetic  treatment.  This  is  by  no  means 
true,  and  my  statistics  enable  me  to  disprove  it.  In  Tables  147 
to  loO,  the  individual  and  average  losses  of  weight  of  00  patients 
above  the  age  of  fifteen  years  during  a  stay  of  over  two 
weeks  at  the  New  England  Deaconess  or  Corey  Hill  Hospitals  can 
b.'  seen.  The  cases  are  arranged  chronologically  according  to  date 
of  entrance  to  the  hospitals.  In  the  first  and  second  groups  of  3D 
patients  each,  the  losses  amount  to  3.07  kilos  and  2.S7  kilos  respec- 
tively, but  it  will  be  noticed  in  the  last  group  of  30  cases  treated 
th.it  the  loss  was  but  !.<>  kilograms  per  patient.  These  statistics 
were  compiled  for  the  first  time  during  March,  1017,  and  they  appear 
to  me  encouraging.  With  more  care  in  the  arrangement  of  the  diet 
it  would  seem  possible  to  prevent  a  considerable  proportion  of  losses 
of  weight  which  now  occur.  While  in  many  cases  such  losses  arc 
beneficial,  they  are  not  desirable  in  all,  and  each  case  deserves  indi- 
vidual attention. 

Eat  diabetic  patients  can  most  easily  acquire  a  tolerance  for 
carbohydrate  by  loss  of  weight.  There  is  no  necessity  for  this  loss, 
being  rapid.  It  should  go  hand  in  hand  with  gain  in  muscle. 

During  the  stay  of  the  first  group  of  patients  treated,  the  loss  of 
weight  per  day  per  patient  was  approximately  100  grams,  in  the 
second  group  Il2.~>  grams,  and  in  the  last  group  f>7  grams  per  day  per 
patient.  If  this  loss  of  weight  should  arbitrarily  be  reckoned  as 
one-half  fat,  it  would  be  equivalent  to  450,  •"><>:'>  and  l2.">7  calories 
respectively.  Since  the  average  weight  of  the  patients  was  (iO,  .10 
and  ,")(')  kilograms,  this  would  represent  the  equivalent  of  S,  0,  and  5 
calories  per  kilogram  body  weight  per  d.iy.  Added  interest  attaches 
to  these  calculations  when  they  are  compared  to  the  caloric  intake' 
for  the  three  groups  of  cases.  As  a  matter  of  fact,  if  we  arbitrarily 
consider  the  loss  of  body  weight  as  due  one-half  to  fat  and  add  the 
equivalent  of  the  same  in  calories  to  the  caloric  intake,  it  will  be  seen 


SUMMARIES  OF   THE   TREATMENT  EMPLOYED          335 

that  the  calories  furnished  the  patient  (luring  the  three  periods  were 
not  far  apart  (20,  30  and  28)  good  proof,  though  indirect,  that 
the  caloric  expenditure  under  the  varying  conditions  was  also  the 
same.  These  figures  will  be  more  carefully  analyzed  in  the  mono- 
graph with  Benedict,  and  in  that  the  data  furnished  by  the  indirect 
calorimetry  of  many  of  these  patients  will  be  available  as  well. 

2.  Loss  of  Body  Protein. — My  desire  to  protect  body  protein  has 
evidently   attained   some   fulfilment,    as   shown  by  the  records  of 
the  protein  intake  of  the  three  groups  of  patients  whose  dietary 
data  have  been  summarized.     In  the  early  group  the  protein  per 
day  per  patient  for  the  first  week  was  but  17  grams,  or  less  than  f 
gram  per  kilogram  body  weight  and  during  the  last  week  it  was 
10  per  cent,  below  1  gram  per  kilogram  body  weight.     In  the  two  later 
series  the  figures  change,  and  in  the  first  week  the  protein  almost 
reached  -i-  gram  per  kilogram  body  weight,  and  in  the  last  week  is 
fully  1  gram.    A  gram  of  protein  per  kilogram  body  weight  appears 
to  me  to  be  the  correct  figure  but  I  shall  not  feel  satisfied  until  the 
patient  receives  this  quantity  on  the  average  during  his  whole  stay 
in  the  hospital.  I  can  see  no  advantage  in  a  loss  of  body  protein,  and 
feel  that  some  means  must  be  found  which  will  improve  the  tolerance 
of  diabetic  patients  without  curtailing  it.     In  the  last  few  months 
I  have    used   fish  frequently  in  the  early  treatment  of    patients, 
because  of  the  easy  way  it  affords  of  giving  protein  apart  from  fat. 
I  shall  watch  with  interest  the  effect  of  treatment  of  cases  along  the 
general  plan  of  the  treatment  of  Case  Xo.  1237  (see  p.  30(5.)    That 
case  appears  successful,  but  should  be   controlled  by  blood-sugar 
determinations  and  by  many  other  cases. 

3.  Total  Calories. — The  gain  in    calories  of  the  third  group  of 
patients  during  the  first  week  as  compared  with  the  first  group  has 
been  of  little  importance,  but  there  has  been  a  steady  gain  in  calories 
during  the  last  week  in  both  the  second  and  third  groups.    At  the 
present  time  the  patients  certainly  go  home  in  better  condition  and 
with  lower  blood  sugars  than  two  years  ago.    Still  the  melancholy  fact 
remains  that  the  patients  leave  the  hospital  with  23  calories  instead 
of  a  permanent,  self-sustaining  diet.     A  gain  in  3  or  4  calories  per 
kilo  would  mean  everything  to  diabetic  patients.     The  shortage  in 
calories  now  is  in  great  part  due  to  the  weekly  "fasting"  day  or 
"half"  day,  and  the  21  and  23  calories  respectively  per  kilo  which 
the  last  group  of  patients  daily  received  on  leaving   the  hospital 
were  chiefly  taken  by   them  during  six   days.    If  one  could  only 
obviate  the  fast  day  or  half-day,  the  diabetic  problem  would  be  a 
good  deal   nearer  solution.     It  is  for  this  reason  that  physicians, 
nurses  and  patients  at  the  New  England  Deaconess  Hospital  have 
watched  with  unusual  interest  the  experiments  with  an  exclusive 
carbohydrate  (levulose)  and  fat  diet  on  one  day  each  week.     The 


3.li<i  TREATMENT 

results  arc  encouraging — as  the  patients  say,  too  good  to  be  true — 
and  1  am  too  conservative  to  advise  others  to  repeat  our  experi- 
ments except  when  the  patient  is  underdose  observation  and  all  con- 
ditions can  be  controlled.  One  can  easily  imagine  the1  feelings  of  Case 
No.  (ill),  who  t\vo  years  ago  fasted  nine  days  to  become  sugar-free  and 
has  fasted  from  one  to  two  days  a  week  for  most  of  the  time  ever  since, 
to  be  able  to  substitute  for  a  fasting  day  a  diet  of  7o  grams  carbohy- 
drate and  7-")  grams  fat  without  showing  a  gram  of  sugar  in  the  urine. 
Unfortunately,  she  cannot  do  this  each  week  and  keep  sugar-free. 

How  small  a  part  alcohol  takes  in  my  plan  of  treatment  is  well 
shown  by  these  tables.  Perhaps  1  should  use  it  more;  1  could  not 
use  it  much  less. 

The  large  quantity  of  carbohydrate  given  .during  the  first  week 
in  the  third  group  is  explained  by  the  giving  of  carbohydrate  in  the 
first  days  of  treatment  in  a  larger  number  of  cases  than  in  the  first 
group.  In  other  words,  today  J  use  preparatory  treatment  more 
frequently  than  fasting  at  the  beginning  of  treatment.  But  it  is 
noteworthy  that  the  average  tolerance  for  carbohydrate  during  the 
last  week,  while  greater  in  the  third  than  in  the  first  group,  is  exactly 
the  same  as  in  the  second. 

That  part  of  the  table  which  relates  to  acidosis  will  be  discussed 
separately  under  the  treatment  of  acid  intoxication  on  page  3X7 

F.     THE  FATAL  CASES  OF  1916. 

A  study  of  the  fatal  cases  of  diabetes  occurring  in  1910  is  given 
herewith,  with  a  view  to  the  prevention  of  similar  fatalities.  These 
cases  are  inserted  with  some  detail,  partly  because  1  wish  to  impress 
upon  myself  the  ease  with  which  these  deaths  might  no\v  be 
avoided.  During  the  year  ending  December  1,  1!)1(>,  370  cases  of 
diabetes  were  seen,  and  )>S,  or  10. !>  per  cent.,  died.  There  were  also 
:>!)  other  deaths  in  this  period  occurring  among  the  patients  seen  in 
the  preceding  eighteen  years.  The  total  deaths  amount  to  77  in  all. 
The  causes  of  death  are  shown  in  Table  Ifd. 

The  significant  feature  in  the  present  report,  is  that  during  the 
year  l!)l(i  the  percentage  of  deaths  due  to  coma  has  dropped  to  1 1 
per  cent.  It  will  be  recalled  that  a  year  ago,  (11  percent,  of  all  my 
deaths  from  diabetes  were  due  to  coma.  'This  is  a  notable  fact. 
It  constitutes  one  of  the  best  measures  of  the  improvement  which  has 
taken  place  in  treatment  and  shows  that  radical  changes  in  the 
management  of  diabetes  must  have  occurred.  The  second  feature1 
of  note  is  the-  deerea.se  in  the  percentage  of  deaths  during  the  first 
year  of  the  disease.  \\  hereas  at  the  Massachusetts  (icneral  I  lospital 
up  to  IS! IS,  ()7  per  cent,  of  all  patients  who  died  of  diabetes  suc- 
cumbed during  the  first  year  of  the  disease,  and  in  the  subsequent 
period  10  per  cent,  so  succumbed,  and  of  my  fatal  cases  up  to  a  year 


THE  FATAL  CASES  OF  1916  337 

ago,  17  per  cent,  were  fatal  during  the  first  year,  I  can  now  say  that 
this  mortality  for  all  my  fatal  cases  has  fallen  to  15  per  cent,  and  for 
the  fatalities  of  1910,  44  per  cent.  In  fact,  of  the  34  cases  dying  of 
coma  only  three  deaths  occured  during  the  first  year  of  the  disease, 
and  the  possibility  of  preventing  two  of  these  deaths  will  be  obvious 
to  any  candid  observer.  Reference  to  these  will  be  made  under 
discussion  of  the  coma  cases.  The  third  feature  is  of  a  discouraging 
nature,  for  a  new  cause  of  death  appears  in  my  records — namely, 
inanition,  and  to  this  3  cases  succumbed.  Inanition,  like  coma,  may 
be  rightly  considered  at  present  as  evidence  of  unsuccessful  treat- 
ment, but  even  if  it  is  said  that  these  3  cases  were  saved  from  coma 
to  die  of  inanition  and  therefore  should  be  counted  as  coma,  these 
cases  may  be  added  to  the  coma  cases  and  still  the  mortality  of 
acidosis  and  inanition  combined  is  but  48  per  cent.,  in  contrast  to 
04  per  cent,  from  coma  for  the  last  eighteen  years. 

TABLE  151. — THE  FATAL  CASES  OF  DIABETES  DUIIIXCJ  1916. l 

1.  Deaths  without  coma 43 

I.  Miscellaneous 9 

Cirrhosis 1 

Inanition 3 

Diabetes 2 

Unknown         3 

II.       Cancer 7 

III.  Tuberculosis .3 

Pulmonary      ....  1 

Meiiingeal 1 

Peritoneal 1 

IV.  Cardiorenal  and  vascular 14 

Cardiac G 

Chronic  nephritis 4 

Cerebral  hemorrhage 3 

Enlarged  prostate 1 

V.  Infections 10 

Pneumonia     .  4 

Influenza 1 

Appendicitis 2 

Acute  pancreatitis 1 

Abscess  lung 1 

Gangrene 1 

2.  Deaths  with  coma ,  34 

Total 77 

it  is  true  that  the  cause  of  death  was  unknown  in  3  cases  and 
was  attributed  to  diabetes — a  doubtful  quantity — in  2  cases,  but 
these  groups  were  represented  in  the  former  series,  and  even  if  all 
of  these  are  added  to  the  37  deaths  from  coma  and  inanition  com- 
bined, the  mortality  due  to  all  these  causes  rises  to  but  .14  per  cent.,  a 

1  Thirty-eight  of   these  oases  were  seen  during  1916  and  thirty-nine  were  among 
patients  seen  in   the   preceding  eighteen  years.     See  Table  44  for  the  combined 
mortality  of  all  cases. 
22 


338  TREATMENT 

figure  sufficiently  below  04  per  cent,  to  he  unimpeachable  evidence 
of  what  has  been  claimed  above. 

1.  Deaths  without  Coma. — (//)  Miscellaneous. — Comment  is  un- 
necessary upon  the  3  cases  classed  as  unknown,  and  the  2  cases 
with  a  death  certificate  diabetes.  On  page  07  the  infrequency  of 
cirrhosis,  from  which  there  was  one  death  this  year,  is  discussed. 

The  deaths  from  inanition  demand  the  closest  scrutiny. 

(1)  Intutition. — Three  deaths  from  inanition  have  occurred  in  my 
series  of  cases  since  the  inauguration  of  the  new  methods  of  treat- 
ment which  had  their  start  with  Dr.  Allen's  articles  upon  fasting. 
No  death  was  attributed  to  this  cause  among  the  many  which 
occurred  in  the  preceding  seventeen  years.  The  word  "inanition" 
is  used  instead  of  the  term  "diabetic  inanition,"  because  the  inani- 
tion does  not  appear  to  be  distinctive  of  diabetes  alone.  Jt  might 
occur  in  connection  with  other  diseases,  and,  in  fact,  the  patients 
do  not  appear  like  diabetics,  the  pain  of  cancer  and  the  anxiety  of 
fever  are  also  lacking.  But  in  each  instance  when  I  pushed  the  diet 
up  above  a  few  calories,  sugar  and  acidosis  appeared  and  experience 
with  other  diabetics  made  it  evident  that  unless  the  diet  was  curtailed 
coma  would  ensue.  Reference  to  the  first  of  these  cases  (p.  08)  has 
been  made  in  the  first  section,  but  1  append  here  brief  summaries  of 
two  of  the  cases  and  their  charts  while  at  the  hospital  (Tables  1  ")2  and 
153).  My  present  feeling  is  that  these  deaths,  too,  are  preventable, 
and  I  hope  that  some  method  of  treatment,  perhaps  similar  to  that, 
described  under  the  experiments  with  levulose,  will  enable  such 
individuals  to  regain  their  tolerance.  I  cannot  make  myself  believe 
that  the  tolerance'  for  carbohydrate  is  wholly  lost  when  the  urine  is 
free  from  both  sugar  and  acid,  and  the  respiratory  quotient  shows 
that  some  material  in  the  body  other  than  protein  and  fat  is  being 
burned,  even  though  the  patient  is  fasting.  (See  pages  380  and  381 .) 

A  little  boy,  ( 'ase  Xo.  1120,  aged  seven  years,  with  diabetes 
of  nine  months'  duration,  beginning  with  7  per  cent,  of  sugar, 
entered  the  New  England  Deaconess  Hospital  in  September,  1(,MO. 
lie  had  been  thoughtfully  treated  in  Vermont,  but  the  urine  had 
not  remained  sugar-free  for  more  than  two  weeks  at  a  time. 
One  week  before  entrance  his  case  became  serious;  nausea  and  deep 
respiration  existed,  and  a  strongly  positive  ferric  chloride  reaction 
appeared  in  the  urine.  lie  became  drowsy  and  dull,  but  not  entirely 
unconscious,  two  days  before  entrance.  He  was  fasted  for  the  three 
days  before  entrance,  and  given  one  teaspoonful  of  sodium  bicar- 
bonate three  times  a  day.  I  pon  arrival  at  the  hospital  his  condition 
had  improved,  but  the  carbon  dioxide  in  the  alveolar  air  was  21  mm. 
mercury,  and  it  fell  to  IN  mm.  the  following  morning.  Then1  was  a 
slight  trace  of  albumin  in  the  urine  and  a  few  finely  granular  casts. 
With  fasting,  the  omission  of  alkalis,  and  small  quantities  of 
carbohydrate  and  protein  he  became  sugar-  and  acid-free,  and 
later  tolerated  carbohydrate  3  grams,  protein  20  grams,  and  fat 


THE  FATAL  CAXES  OF  10 16 


339 


24  grams.  Efforts  to  increase  the  diet  without  the  return  of  sugar 
or  acid  failed;  aeidosis  and  anasarea  appeared.  October  23,  1916, 
I  increased  the  protein  and  fat  of  the  diet,  and  aeidosis  became 
extreme,  deep  breathing  ensued,  and  the  carbon  dioxide  in  the 
alveolar  air  fell  to  15  mm.  mercury  on  repeated  occasions;  but 
again  with  fasting  and  without  alkalis  the  aeidosis  disappeared. 
From  this  time  on  he  gradually  failed,  anasarea  increased,  and  at 
length  petechiye  developed  and  he  died  without  coma  from  exhaustion. 

TABLE  152. — CASE  Xo.  1120.     DIABETES  IN  A  CHILD  OF  SEVEN  YEARS. 
DEATH  FROM  INANITION. 


Urine. 

Diet  in  grains.          ^ 

•3 

O 

Date, 

. 

-T  =           - 

a 

-[ 

•r~ 

N 

% 

1910                 "     Diacetic 

0 

'5jf    a 

>   £ 

a 

0 

C 

~  5 

5-  1 

~  *""  H 

^     :     acid. 

o  ~ 

~3  '    b 

~  ~ 

'C 

^ 

S+3 

^3  t. 

"o  - 

—  ~ 
.ti  M 

53      | 

c 

£ 

i.' 

£ 

J. 

-if  ^ 

s 

<~ 

Sept.     0-  7  .       .      .  .        -f-  +  + 
7-  8  ....            + 

8 
4 

0 
5 

0 
3 

o        0 
0        32 

0 
0 

401 

21 

18 

8-    9  ....          +  + 

14 

10 

14 

0      112 

0 

39' 

9-10  .... 

..17 

15 

15 

0      120 

0       39 

26 

10-1]   .      .      ..          +  + 

6 

10 

5 

0        60 

0       391 

11-12  + 

0 

3 

2 

0        20 

0       39  12 

29 

12-13  ....          +  + 

0 

5 

3 

0        32 

0       39 

13-  1  1  .      .      .  .             0 

r.          0 

3 

20 

6  j  146 

0       38^ 

26 

14-15  ....             0 

0 

3 

24 

24      324 

0       381 

15-10'.       ...           +  + 

11 

4 

29 

44 

528 

0       37! 

Oct.    10-11  .      .    7.8        ++          3.3      1.4      12 

0 

21 

42      402 

0       40J 

11-12  .       .8.8         ++           3.9      1.9      lf> 

10 

21 

3S   :  466 

0       40? 

22 

12-13  .       .2.2           +             5.1      1.4        0 

0 

0 

0          0 

0       39? 

0^32 

13-14  ....            0        |     4.5      1.1        3 

0 

0 

o  :     o 

0       39! 

14-15  ....             0              4.8                    4 

0 

0 

0          0 

0       40 

20 

15-10  ....             0              2.70.711 

20 

0 

0        SO 

0       42'. 

10-17  ....             0              2.7      O.S      19 

20 

0 

0        80 

0       40i 

17-18  ....             0             2.30.1        3 

0 

0 

0  \       0 

0       41.  ', 

18-19         .    0.5           0             3.5      0   1        0 

0 

18 

0        72 

0       41 

19-20  .       .      .  .             0             4.1      0.2        0 

0 

23 

15      227 

0       40i 

0  .  LO 

20  21   ....             0              5.10.2        0 

1 

27 

31      391 

0       40! 

2  1   22  ....             0              .  .           .  .          0 
22  23  ..                      0              20..          0 

6 

20 
0 

45      .>17 
0          0 

0       421 
0       42! 

23-21.       .2.7           0              4.9        .  .          0 

0 

33 

50  ,  582 

0       431 

24-25  .       .     2.7            0         ,4.9          .          5 

0 

33 

50      582 

0       43? 

25-20'.      .2.7           +            4.9     0.8        6 

0 

38 

59  .  683 

0       43? 

20-27  .       .     8.0  '    +  +  +        7.2      1.3      IS 

0 

42 

70      798 

0 

27-28  .       .    8.0 

7.2        .  .       25 

20 

17 

12      256 

0  j     .  .     : 

15 

28-29  .       .8.0           0 

7.2       .  .         7 

0 

0 

0          0 

0 

24 

29-30  .      .5.3           0 

6.4 

4 

0 

0 

0 

0 

0 

25 

30-31   .      .5.3           0 

6.4 

0 

0 

0 

0 

0 

0 

48  1 

20 

Xov.  31-    1  .      .    5.3           0 

0.4 

0 

1 

19 

IS      242 

0 

49? 

26 

1-    2  .      .2.4           ? 

6.6 

0.6       0 

2 

25 

24      324 

0 

50 

33 

2-  3  .      .2.4           ? 

6.6 

0 

5 

33 

30 

422 

0 

51i 

3-  4  .      .2.4           0 

6.6 

0 

0  ! 

0 

0 

0 

0 

5U 

0.18 

26 

4-  5  .      .2.7           0 

8.8 

0 

5 

33 

30 

500 

0 

51  1 

24 

5-  (i  .      .2.7           0 

8.8 

0 

5 

41 

33 

477 

0 

50 

25 

0-  7  .      .2.7           0 

S.S 

0 

5 

41 

35 

495 

0 

51? 

13-U  ....            0 

0 

6 

51 

34 

534 

0 

49 

14-15  ....             0 

2 

7 

54 

39 

595 

0 

51 

15    16  .       .1.0           0 

7.0 

0 

0 

0 

0 

0 

II 

50? 

10-17  .       .1.0           0              7.0 

0 

o  ! 

51 

34 

534 

0 

50? 

17    IS  .           l.o           0              7.0                    1 

6 

51 

34 

531 

0 

53 

l-i-19  ....            0              ...         S 

6 

41 

35 

499 

0 

52! 

19  20  ....     :        0             6.1        .  .          1 

0 

0 

0 

0 

0 

r-]l 

0.28 

20-21   ,       .j     .  .             0              0.1 

0 

1 

27 

23 

319 

0 

21-22  .       .'     ..             0             fi.i 

1 

1 

35 

28 

390 

II 

51? 

22-23  ....             0 

1 

1 

35 

28 

390 

0 

23-  24s.            1   0           0            12.5 

0 

10 

39 

33 

493 

0 

24-25   .       .10            0             12.5 

0 

15 

43 

37 

505 

0 

25-20  .       .     2.2            0 

4.3 

0.3       .. 

30 

12 

0      22  1 

0 

1  Note  influence  of  fat  upon  aeidosis. 

2  Note  terminal  increase  of   urinary  nitrogen  without  glycosuria. 


340 


TREAT  ME  XT 


Case  Xo.  10S5,  a  frail  woman  of  thirty-four  years,  with  a  history 
of  diabetes  of  seven  months'  duration,  entered  the  hospital  in  July, 
1910,  with  a  story  of  great  difficulty  in  keeping  sugar-free  despite 
fasting  and  a  lo\v  diet.  Tuberculosis  was  excluded  by  repeated 
physical  examinations  and  by  the  fluoroscope.  Her  weight  had 
fallen  from  150  to  91  pounds,  and  in  her  stay  of  four  months  at  the 
hospital  dropped  30  pounds  more.  The  urine  remained  free  from 
sugar  and  acid  nearly  all  the  time  except,  when  carbohydrate  '2 
grains,  protein  40  grams,  fat  90  grams  and  alcohol  15  grams 
were  given  for  five  successive  days,  when  severe  acidosis  ap- 
peared and  the  sugar  in  the  urine  steadily  increased.  Levulose 
was  given  on  three  occasions  in  50-,  50- and  75-gram  doses,  with  the 
elimination  of  1,  5  and  15  grams  sugar  respectively.  Ten  days 
after  the  second  test  the  patient  was  just  able  to  be  taken  home. 
She  was  sugar-  and  acid-free,  but  tolerated  only  3  grams  carbo- 
hydrate, 42  grams  protein,  30  grams  fat,  and  30  grams  alcohol 
(()()()  calories).  The  blood  sugar  was  0. 10  per  cent.  A  few  days  later, 
while  remaining  in  the  same  condition,  she  died  without  pain  or  coma. 

TABLE  153. — CASE  No.  10cS").     DIAHETES  IN  A  WOMAN  OF  THIRTY-FOIII  Y  i;  AKS. 
DEATH  FROM  INANITION. 


Urine. 


Diet  in 


II 

1 

( 
( 

87 

88 

s 

I 

87 

0.28 

»7 

( 

84 

7 

( 

84 

41.2 

0.35 

8 

XI 

3 

( 

Si? 

•> 

( 

82 

X 

S3 

1  1 

I 

82 

:i 

( 

82 

0.39 

0 

( 

T'.t 

() 

s 

fifi 

s 

tlii 

0.  '2'2 

0 

tiS 

* 

: 

71 

;| 

r 

71 

.-> 

(i!) 

.", 

I  i!  1 

:{ 

;j 

71 

7 

71 

Such  deaths  1  cannot  believe  necessary,      \\ith  the  evidence  of 
the  high  respiratory  quotients  obtained  during  fasting  (p.  120),  the 


specimen. 


THE  FATAL  CASES  OF  1916  341 

dextrose-nitrogen  ratio  suggesting  that  human  diabetes  is  incomplete 
(p.  132),  and  in  the  presence  of  a  normal  quantity  of  sugar  in  the 
blood,  a  way  should  be  found  to  make  such  deaths  avoidable. 

(b)  Cancer. — Seven  deaths  occurred  from  cancer.     None  of  these 
in  any  way  could  be  brought  into  relation  with  the  diabetes. 

(c)  Tuberculosis. — Many  feared  that  tuberculosis  would  prove  in- 
creasingly frequent  with  the  undernutrition  methods  adopted  these 
last  two  years.    It  is  therefore  significant  that  only  three  such  deaths 
occurred :  one  due  to  tuberculosis  of  the  lungs,  another  due  to  men- 
ingitis accompanying  tuberculosis  of  the  lungs,  and  another  to  peri- 
toneal tuberculosis.    The  rarity  of  tuberculosis  in  the  presence  of 
undernutrition  will  add  largely  to  the  conviction  which  has  already 
been  growing  among  those  who  treat  consumptives  that  hyperfeed- 
ing  should  not  of  itself  be  an  essential  feature  in  the  treatment 
of  pulmonary  tuberculosis 

(d)  Cardiorenal  and  Vascular. — It  is  really  surprising  that  in  dia- 
betes under  the  age  of  sixty  one  so  seldom  meets  with  evidence 
of  valvular  disease  or  failure  of  the  heart.     All  recognize  the  fre- 
quency of  arteriosclerosis  in  old  diabetics,  but  the  rarity  of  heart 
disease  in  young  diabetics  may  not  be  simply  a  coincidence.   Among 
my  fatal  cases  of  diabetes  under  the  age  of  fifty,  so  far  as  I  am  aware, 
not  one  has  died  of  a  valvular  disease  of  the  heart.    Of  the  6 
deaths  from  heart  disease,  3  were  due  to  angina  pectoris.    These 
were  Case  Xo.  355,  whose  lower  extremities  had  been  amputated  on 
account  of  gangrene  four  years  before  (see  p.  423);  Case  Xo.  499, 
who  died  at  the  age  of  sixty-two  years,  duration  of  diabetes  seven 
years;  Case  Xo.  759,  described  in  detail  on  p.  489.    Case  Xo.  1019 
died  of  acute  cardiac  dilatation  two  days  after  simple  drainage  of 
a  distended  bladder,  due  to  an  enlarged  prostate. 

As  regards  the  four  deaths  from  nephritis,  I  can  repeat  what  is 
said  elsewhere,  that  diabetic  patients  with  the  type  of  nephritis 
which  occurs  in  advanced  life  really  appear  to  do  fully  as  well  or 
even  better  than  other  cases  with  the  nephritis  alone,  and  Dr. 
Ilornor  and  I  cannot  but  feel  that  the  carefully  controlled  diabetic 
diet  with  its  low  caloric  value  and — with  these  individuals — low 
protein  and  salt,  must  contribute  to  this  end. 

Three  patients  died  of  cerebral  hemorrhage. 

(e)  Infections. — Infections  claim  a  considerable  mortality.     Infec- 
tions undoubtedly  lower  carbohydrate  tolerance  and  thus  increase 
the  severity  of  the  disease.     They  often  lead  to  a  fatal  issue  in  two 
ways:  (1)  by  favoring  the  onset  of  coma,  which  will  be  discussed 
later,  and  (2)  because  local  infections  often  deter  the  physician 
and  surgeon  from  energetic  treatment.     Thus,  of  the  tAvo  deaths 
from  appendicitis,  one  was  a  fulminating  case,  but  Case  Xo.  753 
had  an  old  history  of  attacks  of  appendicitis,  and  though  he  did  not 


342  TREATMENT 

die  of  a  fulminating  attack  until  five  months  after  leaving  the 
hospital,  it  is  quite  possible  that  had  diabetes  been  absent  the 
appendicitis  would  have  earlier  received  adequate  attention.  Dia- 
betes must  not  be.  considered  a  contra-indication  to  an  operation  for 
appendicitis.  In  this  patient  the  success  with  which  the  teeth  were 
extracted  (p.  4 .'51 )  shows  that  the  appendix  could  have  been  quite 
as  easily  removed.  This  was  done  in  Case  No.  29,  twelve  years  ago, 
and  the  patient  survives  today. 

One  patient  died  of  abscess  of  the  limy  three  months  after  leaving 
the  hospital.  Contrast  this  case  with  Case  No.  12:>9,  p.  44o,  who 
was  successfully  operated  upon  for  the  same  condition.  Jt  is  not 
surprising  that  out  of  the  75  cases  '.}  succumbed  to  pneumonia  at  the 
ages  of  seventy-five,  sixty-five  and  seventy-two  years  respectively. 

The  death  from  acute  pancreatitis  is  of  course  questionable,  because 
there  was  no  autopsy;  but  a  good  surgeon  made  this  diagnosis  when 
he  saw  the  patient,  who  was  a  doctor  of  sixty-five  years.  1  had 
not  seen  the  patient  for  four  years. 

Influenza  caused  one  death.  I  consider  that  we  were  most 
fortunate  at  the  hospital  to  have  avoided  deaths  from  influenza 
and  bronchial  infections,  because  several  contact  infections  devel- 
oped during  the  year.  Realizing  the  seriousness  of  such  infections, 
vigorous  isolation  is  now  practised  and  with  good  results. 

Gangrene  of  the  lower  extremities  was  responsible  for  the  death 
of  one  patient.  He  died  with  a  temperature  of  1()('>°  in  another 
hospital,  three  days  after  operation,  at  which  intraspinal  novocain 
and  local  novocain  were  employed  as  anesthetics.  lie  was  un- 
conscious but 'two  and  a  quarter  hours,  and  death  may  be  attrib- 
uted to  a  continuation  of  the  infection  which  had  existed  for 
four  weeks  before  admission  to  the  hospital.  The  diabetes  was  of 
ten  years'  duration,  and  I  had  not  seen  the  patient  for  the  last  nine 
years.  The  man  was  reported  to  have  kept  sugar-free  during  these 
nine  years,  and  in  fact  immediately  after  operation  the  urine  was 
still  free  from  sugar,  but  contained  much  albumin.  Two  days  after 
operation,  however,  sugar  was  present  in  large  quantity. 

2.  Deaths  from  Coma.  More  than  once  I  have  expressed  the 
conviction  that  deaths  from  coma  in  diabetes  are  usually  avoidable. 
The  decrease  in  the  percentage  of  all  deaths  due  to  coma  from 
C>4  per  cent,  for  the  IS  years,  ending  December  1,  1915,  to  44  per 
cent,  for  the  year  191C>  alone  and  to  (10  per  cent,  for  the  19  year* 
ending  December  1,  19 1C),  together  with  an  analysis  of  the  present 
series  of  cases,  supports  this  claim.  In  Table  154  I  have  analyzed 
these  deaths  from  coma  (1)  according  to  the  duration  of  the 
disease  prior  to  the  onset  of  coma,  (2)  to  the  best  of  my  ability 
according  to  the  condition  predisposing  to  the  development  of 
coma.  To  my  mind  the  conclusion  is  justified  that  although  the 


THE  FATAL  CASES  OF  1916 


343 


first  year  of  the  disease  has  been  for  years  the  clanger  zone  of 
the  diabetic,  modem  treatment  will  now  make  it  what  it  ought 
to  be,  the  safest  year  of  the  life  of  the  diabetic.  For  the  present 
what  was  said  relating  to  the  first  year  as  a  danger  zone  should 
now  be  applied  to  the  second  year  of  the  disease,  and  with  this 
assurance,  that  just  as  the  dangers  in  the  first  year  of  the  disease 
have  been  already  overcome,  the  way  is  clear  by  which  to  overcome 
also  the  dangers  attending  the  second  year  of  the  diabetes.  In 
compiling  Table  154  I  wrote  down  the  cause  for  the  death  of  each 
individual  patient  by  coma  absolutely  without  thought  of  the 
duration  of  the  disease.  The  statistics  are  unbiased  and  the  table 
shows  well  the  opportunities  for  better  treatment  and  also  the 
possibility  for  the  prevention  of  most  of  the  now  regrettable  and 
unnecessary  deaths  from  coma. 

TABLE  154. — CAUSES  UNDERLYING  DEATHS  FROM  DIABETIC  COMA  DURING 

THE  YEAR  1916. 


Duration  of 
diabetes. 

Total 
cases. 

Dia- 
betes 
un-. 
treated. 

Xeglect 
of  pre- 
paratory 
treat- 
ment. 

Obesity; 
high  fat; 
low 
carbo- 
hydrate. 

Patient 
abandoned 
treatment. 

Imper- 
fect 
super- 
vision. 

Increas- 
ing sev- 
erity of 
diabetes. 

Ether 
anes- 
thesia. 

Car- 
buncle. 

2-   6  mos. 

3 

1 

1 

7-12      " 

1 

1 

1  -2  yrs. 

10 

1 

2 

7 

2-3     " 

5 

1 

2 

2 

3-  4     " 

1 

1 

4-  5     " 

4 

2 

1 

1 

5-  6     ' 

3 

1 

2 

6-  7     ' 

2 

1 

1 

7-  8     ' 

2 

1 

1 

12     ' 

i  ••;     ' 

2 
i 

1 

1 

1 

Totals      34 
Per  cent. 


10 


1       1 


6 


21 


The  causes  underlying  the  34  deaths  from  coma  during  191G  were  as  follows: 


(a)  Diabetes  untreated. 

(b)  Neglect  of  preparatory  treatment. 

(c)  Obesity;  high  fat,  low  carbohydrate. 

(d)  Patient  abandoned  treatment. 

(e)  Imperfect  supervision. 


(/)  Increasing  severity  of  diabetes. 

(g~)  Ether  anesthesia. 

(h)  Carbuncle, 

(i)  Unknown. 


(a)  and  (b)  Diabetes  Untreated  and  Neglect  of  Preparatory  Treatment. 
—From  the  above  table  it  will  be  seen  that  three  deaths  from  coma 
occurred  during  the  first  six  months  of  the  disease.  One  of  these  was 
Case  Xo.  1143,  who  had  previously  had  no  treatment  for  diabetes, 
so  far  as  I  am  aware,  entered  the  hospital  in  coma  and  died  fifteen 
hours  later.  Another  patient,  Case  Xo.  1004,  had  been  placed  upon 
the  old-fashioned  fat-protein  diet,  according  to  the  story  of  her 


344  TREATMENT 

physician,  a  few  days  before  entrance,  was  brought  to  the  hospital 
in  an  ambulance,  in  beginning  coma,  and  died  in  fifty-six  hours. 
Details  regarding  the  death  of  the  third  case  are  not  sufficiently 
clear  to  me  to  assign  a  cause. 

((•)  Obesity. — High  Fat  and  Low  Carbohydrate  Diet. — Case  Xo.  974 
died  toward  the  end  of  the  first  year  of  the  disease.  This  patient 
represents  one  of  three  patients — Cases  Xos.  974,  733  and  1058 — who 
died  respectively  nine  days,  nine  months,  and  five  months  after  leav- 
ing the  hospital,  in  the  first,  second,  and  third  year  of  their  disease. 
These  cases  were  not  intrinsically  severe  cases,  but  I  believe  were 
so  by  two  factors:  the  low  quantity  of  carbohydrate  in  the  diet 
and  the  comparatively  large  quantity  of  fat — whether  body  fat  or 
food  fat — upon  which  they  could  draw.  Just  as  Folin's  non-diabetic 
obese  patients  readily  developed  severe  acidosis  upon  fasting,  fat  dia- 
betic patients  can  do  the  same,  though  much  more  readily  upon  a 
fat-protein  diet,  as  illustrated  by  Case  Xo.  983. 

Case  X"o.  983,  a  woman  of  55  years,  onset  in  December,  191.1,  came 
for  treatment  in  January,  1910;  weight,  201  pounds;  height,  5  feet 
3  inches.  An  acidosis  amounting  to  4.3  grams  ammonia  and  an 
alveolar  air  of  21  mm.  Ilg,  which  she  acquired  upon  a  fat-protein 
diet,  did  not  disappear  for  eighteen  days,  but  she  ultimately  left  the 
hospital  eight,  days  later,  with  a  tolerance  for  over  50  grains  carbo- 
hydrate and  80  grams  protein. 

If  the  acidosis  is  not  checked,  it  can  result  within  a  comparatively 
short  time  in  corn  a,  and  it  now  appears  that  even  if  partially  checked, 
and  yet  the  patient  is  allowed  to  live  upon  a  low  carbohydrate  diet 
for  a  period  of  months,  eventually  tolerance  will  be  lost,  as  Allen 
has  shown  for  his  dogs,  and  acidosis  will  claim  the  victim.  The 
treatment  for  these  patients,  therefore,  is  to  withhold  fat  entirely 
at  the  beginning  of  treatment;  as  a  result  the  carbohydrate  toler- 
ance can  undoubtedly  be  raised  to  a  higher  figure  and  the  protein 
as  well.  Gradually  small  quantities  of  fat  may  be  allowed,  but  the 
weight  of  the  patient  should  be  slowly  decreased  how  far  it  is 
impossible  to  say,  and  only  time  will  be  a  guide.  I  believe  it  seldom 
a  good  plan  for  normal  obese  individuals  to  lose  more  than  one 
pound  a  month,  and  I  doubt  if  these  fat  diabetics  would  need  to 
lose  weight  any  more  rapidly. 

These  3  cases  are  so  clear  cut  that  I  am  confident  they  will  awaken 
memories  of  similar  cases  in  the  minds  of  other  physicians.  Their 
deaths  were'  so  regrettable,  and  to  my  present,  thinking  so  easily 
to  be  avoided,  that  I  consider  it  well  worth  while  to  give  them  in 
abstract. 

Case  Xo.  974,  with  onset  in  December,  191  5,  at  the  age  of  twelve 
years  and  eight  months,  came  under  observation  in  January,  1910. 
Height,  144  cm.;  greatest  weight,  38.0  kilos.  It  will  be  seen  from 
his  chart,  Table  15."),  that  he  became  promptly  sugar-free  with 


THE  FATAL  CASES  OF  1016 


345 


fasting  and  acquired  a  notable  tolerance.  In  October,  1910,  he 
returned  to  the  hospital  with  considerable  acidosis,  and  a  high  blood 
sugar,  which  did  not  yield  to  the  short  period  of  treatment,  and  the 
patient  went  home  upon  an  inadequate  diet.  Through  a  mutual 
and  unfortunate  misunderstanding  the  patient  left  the  hospital  long 
before  he  was  in  condition  to  do  so.  The  penalty  was  swift  and 
severe,  for  he  died  in  nine  days. 

TABLE  155. — CHART  OF  CASE  Xo.  974. — DEATH  OF  A  TWELVE-YEAR-OLD 
BOY  NINE  DAY'S  AFTER  DISCHARGE  FROM  THE  HOSPITAL. 


Urine. 

Diet  in 

Ejrams. 

"Pi            1 

Date, 

1910. 

Diaretie 

j  Ammo-    rp       , 

Carbo- 

Pro- 

Fat. 

Calor- 

Blood    Alveolar 
Carbo-     S"f  ar'     air  CO,, 
hydrate      ,              mm.  Hg. 

acid. 

total      su^r' 

tiydrate. 

tein. 

ies. 

balance.      "'nt' 

Knis. 

gms. 

Jan 

18 

(7.2%) 

20 

+  +  +  + 

20-21 

1  .  4         30 

Fas  tin 

!I  18 

hou  rs 

25 

21-22 

+ 

0 

0 

0 

0 

0 

0 

31 

22-23 

+ 

0 

3 

2 

0 

20 

+  3 

29 

23-24 

+  + 

0 

6 

3 

0 

36 

+   6 

24-25 

+ 

0 

15 

21 

6 

198 

+  15 

24 

25-26 

+ 

0 

20 

34 

11 

315 

+20 

26-27 

0 

0 

25 

40 

16 

404 

+25       0.17         32 

30-31 

0 

0 

25 

50 

48 

732 

+  25 

31-   1 

0 

16 

10 

34 

35 

371 

-   6 

Feb 

.     1-  2 

0 

0 

0 

0 

0 

0 

0 

2-  3 

0 

0 

10 

34 

35 

71 

+  10 

3-  4 

0 

0 

25 

46 

52 

752 

+25       0.19 

8-  9 

0 

0 

27 

5'i 

90 

1142 

+  27 

Oct 

4  -  5 

+  + 

2  .  2         27 

40 

5 

0 

180 

+  13          .  .            24 

5     6 

+  + 

2.4         42 

30 

S 

0 

152 

-12       0.43 

6-  7 

+  + 

33 

20 

10 

0 

120 

-13 

7-   s 

-f- 

3 

15 

8 

0 

92 

+  12 

8-  9 

+ 

16 

10 

5 

0 

60 

-   6 

9-10 

SI.  + 

0 

0 

0 

0 

0 

0 

10-11 

0 

0 

0 

0 

0 

0 

0       0.33 

11-12 

0 

0 

10 

5 

0 

60 

+  10 

12-13 

0 

0 

20 

10 

0 

120 

+20       0.50 

13-14 

0 

4 

30 

15 

0 

180 

+26 

14-15 

0 

2 

10 

5 

0 

60 

+  8       0.33 

15-16 

0 

0 

0 

0 

0 

0 

0 

16-17 

0 

0 

5 

37 

53 

645 

+  5 

26 

Died 

at  home  in  en 

ma 

Weight  at  entrance  68  pounds;  at  discharge  68  pounds. 
Phenolphthalein  test,  22  per  cent,  in  two  hours. 

Case  Xo.  1058,  a  woman,  aged  thirty-nine,  years,  developed 
diabetes  in  October,  1915,  and  came  for  treatment  May,  1916. 
Height,  100  cm.;  weight,  74.8  kilos,  in  contrast  to  the  normal 
weight  of  about  00  kilos.  The  onset  was  acute,  in  almost  a 

D 

day,  though  the  exciting  cause  she  considered  a  bad  fright  in  August, 
1915.  She  remained  five  weeks  at  the  hospital,  easily  became  sugar- 
free  with  fasting,  but  in  the  process  acidosis  appeared,  but  was  nearly 


340 


TREATMENT 


dispelled  by  (10  grams  levnlose.  She  acquired  a  moderate  tolerance 
for  carbohydrate,  went  home  in  good  condition  but  died  five  months 
afterward.  (See  Table  1  .")(>.) 

TAHI.E  150. — CHART  OF  CASE  No.   1058. 


Total 
Date,              Diacetic        su^ar 
I'.llti.                   acid.          in  urine, 
RIT1H. 

Diet  in  grains. 

Blood        Alveolar 
Kiifiar,      ,  air  (  '(  )2, 
per  cent.     nun.  Jin 

('arl)o-         Pr 
hydrate.  '    tei 

Fat.        Calories. 

May   is    10              I)              54  ' 

10   20              0                 2 

0                 0              0 

0 

20  21         4-  +  +           0 

0                 0              0 

0 

21   22        4-4-+          0 

20 

)       ,         0 

100 

29 

22-23           4-4-            0 

30              22              0      ,       20S 

23   24           4-4-             2.52 

GO-               ( 

)               0 

210 

0.  14 

21   25             +              0 

40        '     3 

10 

374 

0.  14 

25  2G         SI.   +           0 

30             1( 

)               G 

23S 

32 

20  27           ++             G 

20 

)            2 

us 

33 

27  2S         SI.   +            0 

20             2: 

IS 

330 

3G 

2s  2<)         SI.   +           0 

25             30           22            451 

29-30             0               0 

25              r 

33            4S5 

.'!'' 

i 

June     G-  7              0                0 

33            G 

117          1-12!) 

Nov.         21             Died  in  coma 

Weight  at  entrance  130  pounds.  Weight  at  discharge  125  pounds 

TABLE  157. — CHART  OF  CASE  No.  733. 


Date. 

Diacetif 
acid. 

Total 
suwir  in 
urine, 
grains. 

Carbo- 
hydrate. 

Diet  in 
Protein. 

Drains. 
Fat. 

Calories. 

XallC'O. 

1915 

July   30   31     .       .        +  +  +           !>33 

1 

14 

31-    1     .       .        +  +  +              !) 

0 

3 

4 

Aug.      1      2     .       .             0                   0 

0 

3 

112               4 

23..             0                   0   ' 

5 

34.       .             0                  0 

10 

IS 

15 

SO. 

0                     0 

25 

5G 

71 

10-11     . 

0                    0 

28 

55 

103 

1259 

11-12. 

0                     0 

12    13     .       . 

0 

0 

2!) 

04 

120 

191fi 

Apr.  22    .       . 

Died   in  coma 

.      .__     _ 

Weight  at  entrance  133  pounds.          Weight  at  discharge!  12.~>i  pounds. 

Case  Xo.  Too,  onset  of  diabetes,  at  the  age  of  sixteen  years  and  eight 
months  in  May,  1913,  came  under  observation  in. June,  1014.  Height 
Hi")  cm.,  and  greatest  weight  SO  kilos!  With  fasting  the  patient. 
promptly  became  sugar-free.  Not  recogni/ing  the  importance  two 
years  ago  of  building  up  a  tolerance  for  carbohydrate  and  keeping  the 
fat  low  the  patient  was  discharged  with  a  low  carbohydrate  diet  and 

2  Loyulose. 


THE  FATAL  CASES  OF  in  16  347 

high  quantity  of  fat.  Whereas  this  ease  yielded  promptlyto  treatment 
and  was  undoubtedly  mild  in  type,  death  ensued  in  nine  months  from 
coma. 

(d)  Treatment  Abandoned. — Treatment  was  deliberately  aban- 
doned— not  neglected,  but  actually  given  up — by  8  cases,  constitut- 
ing 25  per  cent,  of  the  deaths  from  coma  and  10  per  cent,  of  the  total 
deaths  for  the  year.  It  is  a  very  poor  excuse  for  a  physician  to 
claim  freedom  from  responsibility  from  a  death  due  to  coma  by 
saying  that  the  patient  abandoned  treatment.  The  physician 
should  make  his  patient  so  much  more  comfortable  undergoing 
treatment  than  neglecting  it  that  treatment  will  be  followed 
throughout  the  course  of  the  disease.  Analysis  of  these  8  cases  of 
patients  who  abandoned  treatment  shows  that  no  one  abandoned 
treatment  during  the  first  year,  but  that  2  cases  did  so  during  the 
second  year.  In  one  instance  this  was  done  by  the  parents  of  a 
little  child  seven  months  after  leaving  my  observation,  and  at  a 
distance  of  over  one  thousand  miles,  and  by  the  parents  of  another 
child  who,  several  months  before  the  death  of  the  child,  ignorantly 
broke  the  diet  and  later  allowed  the  child  to  break  it.  This  child 
died  one  and  a  half  months  after  he  was  last  seen  by  me.  During 
the  third  year  there  were  two  such  deaths;  both  patients  were  adults 
and  severe  cases.  One  case  repeatedly  broke  treatment  in  the 
hospital  and  gave  up  treatment  after  leaving  the  institution,  and 
had  various  difficulties  with  physicians  in  other  hospitals.  The  other 
patient  was  said  to  have  broken  treatment  in  the  hospital; 
openly  renounced  treatment  on  discharge  and  refused  to  have  the 
urine  examined  by  her  local  physician.  One  of  the  two  patients  who 
abandoned  treatment  in  the  fourth  year  was  a  man  whose  diabetes 
was  complicated  by  alcoholism,  and  the  other,  a  nurse,  who  incident- 
ally was  really  at  the  start  probably  a  rather  mild  case.  She  was 
fat  and  today  could  easily  be  kept  in  good  condition  upon  a  fairly 
liberal  carbohydrate  diet.  A  single  case  gave  up  treatment  during 
the  sixth  year.  This  was  case  Xo.  1005,  who  felt  that  she  had  a  full 
knowledge  of  the  disease,  literally  wandered  over  five  thousand  miles 
in  the  course  of  comparatively  few.  months,  broke  treatment  in 
the  hospital,  broke  treatment  outside,  and  reentered  in  coma  and 
died.  Last  of  all  was  a  patient  who  gave  tip  all  treatment  after 
having  the  disease  twelve  years.  Her  case  is  next  described. 

Case  Xo.  927,  with  onset  in  1903  at  the  age  of  forty-five  years, 
came  under  my  observation  in  October,  1915,  at  the  age  of  fifty- 
seven  years,  marked  diabetic  heredity,  greatest  weight  105  pounds, 
but  on  entrance  11 1  pounds.  Height  five  feet  six  and  a  half  inches. 

A  poor,  feeble,  nearly  blind  patient,  tormented  with  pruritus,  with 
an  enlarged  heart  and  liver,  albumin  and  casts,  entered  with  only  a 
small  quantity  of  sugar  in  the  urine  and  a  diet  which  was  partially 


348 


TREATMENT 


satisfactory  to  her.  In  its  ])l;u:e  we  gave  a  diet  adequate  in  calories, 
rich  in  fat,  and  lo\v  in  carbohydrate,  and  produced  thereby  acid 
poisoning.  The  patient  was  unhappy  in  the  hospital,  and  as  I  now 
look  back  on  the  case,  had  reason  to  be.  Contrast  the  treatment 
this  patient  received  with  the  treatment  accorded  Case  Xo.  759 
(see  p.  489)  and  that  of  Case  Xo.  979  as  described  on  p.  308.  It 
should  be  noted  that  the  patient  came  in  without  acidosis  but  it 
followed  fasting;  with  the  acidosis  it  is  quite  probable  that  her  consid- 
erable tolerance  for  carbohydrate,  which  must  have  existed,  fell. 

TABLE  158. — CHART  OF  CASE  Xo.  927. — ILLUSTRATION  OF  POOR  TREATMENT 

OF  A   DiAi'ETie  CASE  OF  TWELVE  YEARS'   DURATION.     SEE  TABLES 

142  AND  143  FOR  EXAMPLES  OF  BETTER  TREATMENT. 


Date, 
1915. 


Total 
Diacetie      sugar  in 
acid.             urine. 

Diet  in  grains. 

farbo-        Pro-         r 
hydrate.       toin. 

i    Carbo- 
it.        Alcohol.      C'alories.      liydrate. 
balance. 

Nov.     1      2 


0-  7 


+  + 


0 

3 

10 

0 

0 

3 

1 

0 

3 

1 

o 

15 

s 

o 

15 

8 

0 

15 

20 

15 

15 

35 

10 

15 

11 

21 

15 

11 

21 

15 

41 

40 

0 

0 

3 

21  i 

s 

1 

29 

2S 

1 

29 

2s 

1 

31 

41 

1 

31 

11 

0 

-23 

40 

_  2 

12 

0 

IS 

142 

+  3 

IS 

21S 

+  15 

IS 

218 

+  15 

is 

325 

+  15 

18 

470 

+  15 

18 

539 

+  15 

IS 

539 

+  15 

(I 

080 

+  15 

(i 

42 

0 

(i 

206 

+  25 

0 

414 

+  1 

(i 

414 

+  1 

0 

551 

+  1 

(i 

55  1 

+  1 

The    problem    before    the    physician,   therefore,    in    preventing 

abandonment  of  treatment  is  (1)  tin'  education  of  the  patient  and 
the  relatives  and  C2)  the  improvement  of  treatment  so  that  the 
greatest  possible  tolerance  for  carbohydrate  can  be  acquired  and 
the  diet  made  easier  to  follow.  To  do  this  would  have  been  possible 
both  in  Case  Xo.  707  and  Case  Xo.  927.  Two  of  the  other  patients 
were  so  dishonest  that  it  is  a  question  whether  this  tendency  could 
have  been  controlled,  but  I  believe  that  even  with  these,  more  care 
and  the  demonstration  of  the  advantages  of  strict  adhesion  to  rules 
and  graphic  illustrations  of  the  harmful  ness  of  breaking  treatment  by 
living  examples  might  have  led  to  the  avoidance  of  an  untimely  end. 
It  is  notable  that  in  only  one  death  did  alcoholic  habits  play  a  part. 

1  Hloud  auf^ar,  0.23  per  cent.  -  Alveolar  air,  35  mm.  Tin. 


THE  FATAL  CASES  OF  1916  349 

(c)  Imperfect  Supervision. — Imperfect  supervision  led  to  the  death 
of  7  cases  during  the  first  and  second  year  of  the  disease  and  three 
deaths  in  subsequent  years.  More  deaths  therefore  were  caused  by 
imperfect  medical  supervision  than  in  any  other  way.  This  is  a 
reproach  and  an  encouragement  at  the  same  time.  It  will  radically 
affect  my  own  treatment  of  diabetic  patients;  it  shows  the  necessity 
first  for  better  education  of  the  patient,  so  that  when  not  doing 
well  the  advice  of  a  physician  shall  be  sought;  it  shows  also  the  need 
for  closer  cooperation  between  the  family  physician  and  the  physi- 
cian who  sees  the  patient  in  consultation  or  at  the  hospital,  and, 
above  all,  it  shows  the  necessity  for  simplification  of  methods  of 
treatment,  (loser  supervision  of  the  cases  demands  an  enormous 
amount  of  time,  but  time  so  spent  will  be  repaid  by  lives  saved. 
All  of  us  must  devote  more  time  to  our  cases,  and  we  must  run  the 
risk  of  the  opprobrium  of  forcing  ourselves  upon  patients  by  calling 
to  their  attention  or  the  attention  of  their  physicians  the  need  of 
constant  supervision.  Patients  must  understand  the  facts  and  be 
made  to  realize  that  lack  of  supervision  often  means  needless  death. 
Each  physician  has  it  in  his  own  hands  to  protect  the  lives  of  his 
diabetic  patients. 

(/)  Increasing  Severity  of  Diabetes. — Increasing  severity  of  the  dia- 
betes may  have  been  the  cause  of  death  of  seven  of  the  coma  cases. 

TABLE  159. — DEATH  ix  COMA  DUE  TO  INCREASING  SEVERITY  OF  THE  DISEASE. 

Ago  at  Duration, 

Case  Xo.  oiisut.  years. 

363  ...  14  5.0 

298  ...  10  7.0 

181  ...  43  12.0 

534  ...  9  5.G 

552  ...  30  4.8 

821  ...  23  2.4 

775  ...  7  2.3 

Though  from  four  months  to  six  years  elapsed  from  the  last  time 
I  saw  these  patients  until  death,  a  considerable  share  of  the  responsi- 
bility rests  upon  me,  for  in  most  instances  I  was  frequently  consulted 
about  treatment,  and  in  all  of  these  cases  treatment  was  quite  closely 
followed;  and  though  in  no  instance  was  the  treatment  as  good  as 
could  be  offered  today;  on  the  other  hand,  the  treatment  was  infin- 
itely better  than  the  treatment  afforded  my  patients  ten  years  ago. 
It  will  be  noticed  that  nearly  all  these  cases  were  of  many  years' 
duration.  Certainly  doubt  arises  as  to  whether  the  increasing 
severity  of  diabetes  is  a  proper  title  for  these  deaths.  AVith  what  is 
known  about  the  prevention  of  coma  today,  I  think  it  likely  that 
this  could  have  been  deferred  in  at  least  two  of  the  cases  which 
were  complicated  with  infections,  and  I  think  the  criticism  entirely 


Coma  associated 

Period  between 

with 

last  visit  and  death. 

"Grip" 

3  1  years 

G 

Bronchitis 

4    months 

"Grip" 

31  years 

1    year 

5    months 

1    year 

350  TREATMENT 

justifiable  that  though  increasing  severity  of  diabetes  may  have 
caused  these  deaths,  the  deaths  occurred  too  soon. 

(())  Ether. — During  191(>  the  death  of  one  patient  may  have  been 
due  to  ether  anesthesia.  This  was  a  man,  aged  seventy-two  years, 
with  gangrene;  duration  of  diabetes  over  six  years.  Though  lie 
showed  no  aeidosis  before  the  operation,  he  promptly  developed  it 
aftenvard  and  rapidly  succumbed.  I  did  not  anticipate  such  a  death, 
and  I  believe  that  it  might  have  been  avoided. 

(h)  Carbuncle. — A  carbuncle  this  year,  as  in  the  preceding  year 
(CaseXo.  ">lo,  p.  •)").")),  was  responsible  for  the  death  of  one  patient. 
This  patient  (( 'ase  Xo.  904)  had  had  diabetes  for  fifteen  years,  and  was 
in  quite  fair  condition  when  he  entered  the  hospital.  I  had  seen  him 
off  and  on  for  several  months  outside  when  he  had  absolutely  refused 
entrance  to  the  institution,  though  offered  free  board  and  free  treat- 
ment. When  a  carbuncle  developed  and  he  was  forced  to  enter,  the 
difficulty  of  treatment  was  greatly  enhanced.  The  treatment  of 
carbuncles  is  discussed  on  page  429. 

G.     CASES  UNSUCCESSFULLY  TREATED  BY  FASTING. 

Under  this  heading  will  be  discussed  certain  cases  treated  during 
the  year  and  a  h;'lf  prior  to  December  1,  191"),  which  present 
features  not  sufficiently  emphasized  in  the  fatal  cases  reported  in 
the  preceding  section.  In  addition  to  simply  reporting  the  cases 
I  have  now  added  critical  comments  based  upon  the-  experience  of 
another  year.  Of  12.")  patients  treated  by  fasting  beginning  May, 
1914,  14  patients  had  (lied  by  December  1,  191.").  A  study  of  the 
14  fatal  cases  sho\vs  plainly  that  several  of  the  deaths  might  have 
been  avoided  or  deferred.  Thus  '.>  of  these  patients  were  among 
the  first  cases  fasted  and  treatment  was  incomplete;  the  abandon- 
ment of  treatment  by  the  physician  in  one  instance  and  by  the 
patient  in  another  accounted  for  t\vo  more  deaths  and  lack  of  medical 
supervision  for  a  sixth.  A  seventh  death  was  due  to  cancel1  of  the  blad- 
der and  death  ensued  because  of  a  recurrence  of  the  growth  in  the  scar 
of  the  abdominal  incision  forty-one  days  after  the  primary  operat  ion ; 
the  death  of  another  patient  also  appeared  to  be  entirely  independent 
of  the  diabetes,  and  no  other  diagnosis  than  arteriosclerosis  could  be 
made.  The  remaining  <>  cases  deserve  a  more  extended  notice. 

1 .  Death  Caused  by  the  Inauguration  of  a  Fat-protein  Diet  in  a 
Child.-  (  HSC  Xo.  S( '»."),  ;iged  two  years  and  two  months,  developed 
diabetes  three  weeks  before  coining  under  my  observation,  May  24, 
191.").  A  grandmother  has  diabetes.  The  patient  was  said  to  have 
had  (')..")  per  cent,  of  sugar  early  in  May,  and  was  reported  to  have 
1.2  per  cent,  of  sugar  on  May  -'.},  but  the  urine  voided  on  the 
evening  of  May  24  showed  4.4  per  cent,  of  sugar,  with  a  marked 


CASKS   UNSUCCESSFULLY   THE  AT  ED  BY  FASTING       351 

reaction  for  diacetic  acid,  a  slight  trace  of  albumin  and  an  abun- 
dance of  granular  casts.  Prior  to  admission  to  the  hospital,  the 
patient  had  been  put  upon  a  nearly  fat-protein  diet,  and  although 
his  condition  appeared  fairly  satisfactory  when  first  seen  at  10 
o'clock  at  night  on  May  24,  he  had  clear  signs  of  diabetic  coma  the 
following  morning.  Despite  fasting,  which  began  upon  entrance, 
salt  solution  by  rectum  and  alkalis  by  mouth,  he  steadily  failed, 
although  on  the  following  day  the  respiration  was  not  as  typical 
of  coma  as  before.  Later  complete  coma  ensued  with  death  on  the 
evening  of  May  26.  The  last  specimen  of  urine  examined  on  May 
2(5  showed  no  sugar  and  no  diacetic  acid. 

March,  1917,  comment  upon  treatment  of  Case  Xo.  805.  The 
death  of  this  child,  in  the  light  of  our  present  knowledge,  I  consider 
absolutely  unnecessary.  Several  days  before  the  child  came  to 
Boston  his  physician  telephoned  me.  I  should  have  advised  him  to 
give  the  little  boy  a  saucerful  of  5  per  cent,  vegetables  and  an  orange 
at  each  meal,  or,  if  he  preferred,  either  a  small  saucer  of  oatmeal  or 
half  a  shredded  wheat  biscuit  in  place  of  the  orange,  with  not  over 
a  gill  of  milk  in  the  twenty-four  hours.  Even  a  little  fish  or  lean 
chicken  would  be  allowable.  I  should  have  forbidden  fat  in  any  form. 
As  a  result  the  sugar  would  have  quickly  dropped  and  a  day  or  two 
later  the  total  diet  could  have  been  curtailed  if  necessary  and  the 
child  would  have  been  sugar-free;  acidosis  would  not  have  appeared 
at  any  time  and  tolerance  could  have  been  built  up  in  easy  stages. 
How  needless  the  early  death  of  this  little  child!  The  case  has 
many  analogies,  notably  the  patient  reported  by  Geyelin  and 
DuBois  (see  p.  114),  but  with  this  difference:  they  saved  their 
patient.  If  I  should  allow  another  such  case  to  occur,  I  should 
blame  myself  as  much  as  would  a  surgeon  to  have  a  general 
peritonitis  follow  the  removal  of  an  "interval  appendix." 

Suppose  the  physician  had  not  telephoned  and  that  I  heard  of  and 
saw  the  case  for  the  first  time  when  he  entered  the  hospital  at 
10  P.M.  The  indications  were  plain.  He  had  travelled  one  hundred 
miles  and  had  eaten  hearty  food  both  late  at  night  and  on  the  train, 
and  the  bowels  had  not  moved.  The  stomach  and  bowels  should 
have  been  promptly  emptied.  Milk  of  magnesia  or  an  enema,  or 
both,  should  have  been  given  at  once.  With  a  clear  digestive  tract 
the  next  morning  a  little  oatmeal  water  gruel  or  albumin  water  and 
orange  juice  could  have  been  given  until  the  early  stages  of  approach- 
ing coma  had  been  dispelled.  As  it  was  I  allowed  the  child  to  go 
to  sleep  with  stomach  and  bowels  full,  gave  alkalis  the  following 
morning,  thus  causing  nausea  and  setting  free  acids  which  could  not 
then  be  eliminated  because  of  the  difficulty  of  giving  the  child  suffi- 
cient liquid,  and  in  consequence  coma  ensued.  I  nder  similar  con- 
ditions today  I  believe  the  chances  of  saving  this  child  would  be  10 


352  TREATMENT 

to  1  in  his  favor.  Note  that  with  the  involuntary  fasting,  induced 
by  my  poor  treatment,  sugar  and  diacetic  aeid  disappeared  before 
death  ensued. 

For  those  who  may  be  skeptical  of  my  views  about  the  treatment 
of  such  cases,  I  would  refer  to  Cases  Xos.  1)23  and  0:58,  Tables  212 
and  213  respectively,  who  were  treated  by  fasting. 

2.  Intercurrent  Infections.  Intel-current  infections  played  an 
important,  role  in  the  death  of  2  cases.  It  has  already  been  pointed 
out  that  an  infection  lowers  tolerance  for  carbohydrate,  in  other 
words,  increases  the  severity  of  the  diabetes.  The  greatest  caution, 
therefore,  must  be  adopted  in  the  management  of  such  patients. 
The  records  of  the  following  2  cases  illustrate  several  errors  in  man- 
agement: 

Case  No.  So").  Acute  gangrenous  appendicitis.  A  gentleman, 
aged  seventy  years,  weighing  220  pounds,  with  diabetes  of  ten  years' 
duration,  was  first  seen  four  days  after  an  operation  for  appendicitis 
at  which,  to  the  great  regret  of  the  surgeon  and  physician  in  attend- 
ance, it  was  necessary  to  use  a  large  quantity  of  ether.  This  was  in 
part  due  to  one-fourth  grain  of  morphin  given  subcutaneously 
preliminary  to  operation,  which  so  reduced  the  respiratory  excursion 
that  nitrons  oxide  was  a  failure,  and  a  large  quantity  of  ether  was 
required.  The  patient  had  developed  an  acute  appendix  while 
returning  from  the  South,  April  0,  1915.  On  April  1 1  the  white  count 
was  17,000  and  the  temperature  100°.  On  April  12  the  sugar  in  the 
urine  was  11  grams  and  that  in  the  diet  IS  grams.  On  April  13, 
the  date  of  the  operation,  the  patient  took  14  grams  of  carbo- 
hydrate in  the  diet  and  voided  24  grams  of  sugar  in  the  urine  and 
0.7  gram  ammonia.  lie  underwent  almost  complete  fasting  for  the 
four  days  subsequent  to  the  operation,  yet  failed  to  become  sugar- 
free,  and  general  circulatory  weakness  increased.  The  wound 
progressed  satisfactorily.  Subsequently  he  was  given  whites  of 
eggs  and  vegetable  broths,  with  the  result  that  the  sugar  in  the 
urine  rose.  Later,  further  additions  to  the  diet  were  made,  with 
the  same  result,  and  he  finally  died,  eight  days  after  the  operation, 
being  conscious  up  to  the  last  minute. 

March,  1017,  comment  upon  Case  Xo.  S55.  In  view  of  the 
serious  situation  from  the  diabetic  stand-point  namely:  (1)  a  case 
of  ten  years'  duration;  (2)  a  fat  man;  (3)  an  infeetion-  fat  should 
have  been  omitted  from  the  diet  April  9  and  the  food  allowed 
should  have  been  in  the  Form  of  water  gruels,  the  quantity  of  carbo- 
hydrate approximating  that  taken  by  the  patient  in  the  immediate 
past.  This  diet  would  be  continued  after  the  operation,  adding 
thereto  protein  in  simple  form  as  soon  as  it  could  be  borne.  There 
would  be  no  need  of  adding  fat,  for  he  weighed  220  pounds.  A 
relatively  large  quantity  of  carbohydrate  is  indicated  because  fat 


CASES   UNSUCCESSFULLY   TREATED  BY  FASTING       353 

patients  easily  develop  acidosis  upon  fasting,  yet  their  disease  is 
mild  and  with  moderate  restriction  of  calories  their  truly  high 
tolerance  for  carbohydrate  becomes  manifest.  From  my  knowledge 
of  the  patient  I  doubt  if  the  operation  could  have  been  performed 
without  ether,  but  the  conditions  which  led  to  the  large  amount  of 
ether  being  used  could  be  avoided  in  another  case.  Under  the  best 
of  conditions  recovery  would  be  exceptional. 

Case  Xo.  513.  Multiple  carbuncles  and  septicemia.  This  case 
has  few,  if  any,  counterparts  in  the  literature,  and  is  therefore 
reported  in  detail.  It  is  remarkable  for:  (1)  an  average  loss  of  weight 
of  1.0  kilograms  (3.5  pounds)  daily  for  eleven  days;  (2)  the  excretion 
of  between  31.6  to  37. S  grams  nitrogen  daily  for  the  six  days  pre- 
ceding death;  (3)  a  dextrose-nitrogen  ratio  of  3.67  :  1,  when  nearly 
fasting;  (4)  a  variation  in  the  daily  excretion  of  sodium  chloride 
between  the  limits  of  3.3  grams  and  35.8  grams.  Onset  of  diabetes 
in  October,  1911,  at  the  age  of  thirty-three  years,  and  first  came 
under  observation  in  July,  1912.  At  that  time,  while  at  the  hospital, 
he  became  free  from  acidosis,  but  not  from  sugar.  During  the 
next  three  years  he  worked  hard  in  a  market,  living  upon  a  partly 
restricted  diet.  lie  was  not  seen  except  during  August,  1912,  and 
July,  1913.  Upon  July  29,  1915,  he  tottered  into  the  office  with  a 
carbuncle  on  the  neck  of  eleven  days'  duration,  and  at  once  entered 
the  New  England  Deaconess  Hospital.  During  the  first  two  weeks 
(July  29  to  August  12)  in  the  hospital  the  change  in  the  condition 
of  the  patient  was  favorable,  and  the  surgeon  said  the  carbuncle 
did  as  well  as  with  a  non-diabetic  patient.  Deep-seated  abscesses 
then  began  to  appear  in  various  parts  of  the  body,  and  the  patient 
began  to  lose  weight,  and  in  the  last  ten  days  before  his  death,  on 
September  2,  rapidly  failed.  His  condition  was  most  pitiable, 
complicated,  as  it  was,  with  the  pains  of  multiple  carbuncles,  extreme 
weakness,  and  septicemia.  Death  occurred  thirty-five  days  after 
entrance.  (See  Table  160.) 

It  will  be  seen  that  he  was  fasted  for  six  days,  save  for  48  grams 
of  alcohol  daily,  and  on  the  following  four  days  took  18  to  50  grams 
protein  and  from  15  to  27  grams  fat  each  twenty-four  hours.  He 
was  then  allowed  a  slightly  greater  quantity  of  protein  and  fat  for 
two  days,  then  again  fasted  for  two  days,  when  the  urine  became 
free  from  sugar  and  the  acidosis  disappeared.  The  diet  was  again 
increased,  but  sugar  returned,  even  amounting  to  40  grams  in 
twenty-four  hours,  although  the  carbohydrate  in  the  diet  was  1 
gram,  the  protein  73  grams,  and  the  fat  98  grams.  After  four  days 
of  fasting  the  quantity  of  sugar  in  the  urine  fell  to  only  46  grams. 
From  this  time  on  he  was  given  no  carbohydrate  and  from  37  to 
12  grams  of  protein  and  46  grams  of  fat  on  four  successive  days; 
then  several  more  fasting  days  were  employed,  yet  at  no  time  did 
23 


oo[;[ 


•  <N      •  M  <M        <M  CO       <^i 

'o    'o  o     c  o     o 


.  p  *f  oo  »•<  r- 1>- r-  r—  "5  o  o  •,£  o  >fi>  •*  o  o  us  to 


. 

o  —.  c-.  o  cr.  ~.  o     cr.  cr.  c-.  c:  ~  cr.  ~.  ~  o     c-.  c.  cv  c- 


r-^-fOCO^OOOCOOCO 

I      I      I      I      I      I      I      I      I      I      I      I 


-i     co 

^-i     o 


+   + 


-f  •+- 


i-      00      O! 


( 354 ) 


M  -t  "c  m  M  ~i  sr.  y.  c;  c  c:  cr-  '^ 


-co    •    •    -co 


;•  o  —  •><  —  r-  ?i  -r  -r  o  ••  o  -*  -*•  c-i  ~r  ~>  c  ^t 


K  -r  •?.  -*  cr.  •*  —  <  c  —  o  o  —  o 


+     +     + 

+     H       -J- 


+  + 
+  + 
+  + 


( 355 ) 


356  TREAT  Ml':  XT 

he  become  sugar-free.  Aeidosis  steadily  increased  and  he  finally 
died,  undoubtedly  with  acid  poisoning,  but  not  in  coma,  on  Sep- 
tember 2,  191o.  A  blood  culture  made  immediately  after  death 
showed  a  pure  growth  of  Staphylococcus  aureus. 

Carbon  Dioxide.— The  carbon  dioxide  tension  of  the  alveolar 
air  was  29  mm.  in  the  morning  and  25  mm.  during  the  afternoon 
of  the  day  of  admission,  July  29,  and  gradually  rose  after  the  daily 
administration  of  32  to  4S  grams  sodium  bicarbonate  in  seven  days 
to  54  mm.,  and  it  will  be  seen  that  this  persisted  even  when  smaller 
doses  of  alkali  were  given.  On  August  1 1  the  carbon  dioxide  tension 
amounted  to  4.~>  mm.  mercury,  although  no  sodium  bicarbonate 
was  given  that  day.  Later  it  decreased,  coincidently  with  the 
development  of  metastatic  abscesses,  and  despite  SO  grams  more  of 
sodium  bicarbonate,  it  kept  in  the  neighborhood  of  22  mm.  mercury. 

IHacctic  Acid. — Diacetic  acid  was  present  throughout,  except 
for  two  days. 

Ammonia. — The  ammonia  was  3.7  grams  during  the  first  days 
at  the  hospital;  later  decreased  to  the  neighborhood  of  1  gram,  but 
during  the  last  few  days  of  life  rose,  reaching  5  grams  in  twenty- 
four  hours,  four  days  before  death,  although  90  grams  of  sodium 
bicarbonate  were  taken  daily  during  this  period. 

Xitroyen. — The  nitrogen  remained  practically  constant,  between 
9.3  grams  and  12.5  grams,  during  the  first  ten  days  of  fasting  and 
a  low  diet.  In  the  following  feeding  period  two  observations  showed 
that  it  rose  slightly,  but  the  striking  feature  of  the  nitrogen  excretion 
was  the  marked  elimination  during  the  last  six  days  of  life,  when  it 
varied  between  31.0  grains  and  37. S  grams,  although  the  patient 
took  almost  no  food.  How  long  the  nitrogen  had  been  high  it  is 
impossible  to  say,  but  the  marked  increase  in  nitrogenous  excretion 
can  hardly  be  explained  by  the  washing  out  of  retained  nitrogen, 
for  at  this  period,  although  there  were,  no  carbohydrates  in  the 
diet,  the  amount  of  sugar  in  the  urine  was  considerable,  from  72  to 
125  grams,  and  it  will  be  seen  that  the  dextrose-nitrogen  ratio  at 
this  time  was  approximately  3  :  1. 

Xodiinii  Chloride.  -During  a  portion  of  the  period  of  observation 
the  salt  in  the  urine  was  determined  quantitatively.  It  will  be 
noted  that  this  was  very  lo\v  --4.7  grams  to  3.3  grams — ten  days 
after  entrance  to  the  hospital.  During  the  latter  portion  of  the 
fasting  period,  August  24  -20,  it  was  about  normal -S. 7  grains 
to  12J')  grams  but  on  the  following  days  it,  rose  with  remarkable 
rapidity  to  20,  35. S,  and  35.0  grains.  The  great  increase  in  the 
excretion  of  nitrogen  was  also  striking,  and  would  lead  one  to  con- 
clude' that  the  increased  excretion  of  both  salt  and  nitrogen  was  due 
to  a  washing  out  of  the  system  of  loosely  stored  nitrogen  and  salt, 
were  it  not  for  the  fact  that  the  sugar  in  the  urine  rose  as  well.  One 


CASES  UNSUCCESSFULLY  TREATED  BY  FASTING   357 

cannot  logically  attribute  the  increased  excretion  of  sugar  to  a 
washing  out  of  body  sugar,  because  the  percentage  of  sugar  in  the 
blood  throughout  this  period  remained  practically  constant,  and 
the  diet  contained  no  carbohydrate.  It  is  more  logical  to  conclude 
that  the  sugar  and  nitrogen  stand  in  relation  and  that  the  sugar  in 
the  urine  really  comes  from  body  protein,  but  before  accepting 
this  conclusion  the  remarkable  changes  in  body  weight  must  be 
considered. 

Body  Wciglii. — The  weight  of  the  patient  July  30  was  62.7  kilo- 
grams (138  pounds),  and  on  August  6,  GO. 7  kilograms  (147  pounds), 
although  the  total  calories  ingested  by  the  patient  during  these 
seven  days  amounted  to  2531,  or  362  per  day.  Therefore  this  gain 
in  weight  must  have  been  due  to  a  retention  of  water.  Explana- 
tion of  this  is  afforded  by  the  288  grams  of  sodium  bicarbonate 
given  during  these  seven  days.  Further  evidence  that  sodium  bicar- 
bonate was  retained  in  the  body  is  furnished  by  the  coincident  gain 
in  the  COo  tension  of  the  alveolar  air.  On  August  5  the  quantity 
of  sodium  bicarbonate  had  been  reduced  to  24  grams,  and  during 
the  following  five  days  was  reduced  still  more,  until  on  August 
10  it  was  entirely  omitted.  Yet  during  this  period  the  weight 
continued  to  rise  O.S  kilogram  (If  pounds).  Edema  was  manifest, 
but  not  very  marked,  even  when  the  weight  was  greatest.  During 
the  following  nine  days,  August  11  to  19,  no  sodium  bicarbonate 
was  given,  and  the  weight  rose  0.3  kilo  (f  of  a  pound)  more;  but 
from  this  period  on  it  steadily  fell,  and  in  eleven  days,  August 
19  to  30,  dropped  from  67. S  kilos  (149^  pounds)  to  51.8  kilos  (113| 
pounds),  a  loss  of  1.6  kilos  (3.5  pounds)  per  day.  This  rapid  loss 
in  weight  was  not  detected  in  the  first  few  days,  because  the  patient 
was  so  feeble  and  in  such  pain  from  multiple  carbuncles  that  it 
was  difficult  for  him  to  be  moved;  but  on  August  30  this  remarkable 
loss  was  proven.  The  actual  loss  may  have  been  greater,  for  during 
this  period  SO,  96  and  96  grams  sodium  bicarbonate  were  adminis- 
tered on  respective  days,  and  before  this  alkali  was  given  the  weight 
may  have  been  lower.  As  a  matter  of  fact,  it  did  rise  during  the 
following  forty-eight  hours  to  52.4  kilos  (115|  pounds),  when  144 
grams  of  sodium  bicarbonate  were  taken.  The  weight  of  the  body 
immediately  after  death  dropped  to  51.8  kilos  (114  pounds). 

The  striking  loss  of  1.6  kilos  (3.5  pounds)  body  weight  daily  for 
eleven  days,  and  the  coincident  increase  in  sugar  and  nitrogen 
excreted,  suggest  very  important  changes  taking  place  in  the 
metabolism.  They  indicate  in  a  striking  manner  the  importance  of 
maintaining  reserve  fluid  in  the  body.  So  shrewd  a  therapeutist 
as  Hodgson  has  recognized  the  advantage  of  having  patients  drink 
large  quantities  of  mildly  alkaline  water.  The  therapeutic  benefit 
which  his  clinical  sense  showed  him  to  result  from  this  procedure 


358  TREATMENT 

secures  striking  confirmation  in  these  figures.  Furthermore,  they 
suggest  the  importance  of  studying  the  weight  of  severe  diabetic 
patients,  preceding,  during  and  after  corn  a.  We  recall  no  figures 
which  show  so  rapid  a  loss  of  weight  in  a  diabetic  patient. 

March,  1017,  comment  upon  Case  Xo.  513.  This  man  had 
14,S31  calories  in  twenty-five  days,  and  if  we  deduct  the  calories 
from  alcohol,  he  had  only  11,57(5  calories  in  twenty-five  days,  or  an 
average  of  4(50  calories  per  day  the  entire  period.  He  should  not 
have  been  allowed  out  of  bed!  The  low  caloric  diet  may  to  a  con- 
siderable extent  have  accounted  for  the  marked  protein  disintegra- 
tion immediately  preceding  death.  Case  No.  110(5,  without  an 
infection,  showed  the  same  during  extreme  inanition  and  yet  recov- 
ered. The  diabetes  was  not  extremely  severe  at  the  beginning.  J  am 
inclined  to  believe  that  with  omission  of  fat,  gradual  reduction 
of  carbohydrate  and  protein,  and  the  avoidance  of  alkalis  the 
patient  would  have  become  sugar-free  more  rapidly.  The  increase 
of  sugar  coincidently  with  the  increase  of  fat  in  the  diet  is  beauti- 
fully shown  August  15-1(5  to  August  IS- 10.  Unquestionably 
gradual  increase  of  protein  and  fat  would  have  produced  better 
results  and  the  gathering  cloud  of  acidosis  might  have  been  dispelled. 
The  cardinal  failure  here  on  repeated  occasions  was  the  too  rapid 
increase  of  food.  Very  likely  this  patient  \umld  have  even  shown 
some  tolerance  for  carbohydrate.  With  acidosis  conquered,  a 
greater  caloric  intake  rendered  possible  by  a  progressively  increasing 
diet  and  the  avoidance  of  so  much  fasting,  the  resistance  of  the 
patient  might  have  been  better  and  metastatic  abscesses  and  car- 
buncles might  not  have  developed.  I  am  not  inclined  to  follow 
Christie's'  example  and  fast  another  such  case  eleven  days  to  make 
the,  urine  sugar-free,  but  I  shall  try  first  to  conquer  acidosis,  recom- 
mend the  simplest  possible  surgical  measures  for  the  carbuncle 
and  endeavor  to  maintain  nutrition.  Xo  alkalis! 

3.  Diabetes  of  Long  Duration. — Changes  in  the  diet  and  regime 
of  patients  who  have  suffered  from  diabetes  for  many  years  are 
a  1  \vays  dangerous,  and  particularly  so  in  the  cases  of  extraordinary 
length.  Treatment  of  such  individuals  should  never  be  undertaken 
lightly  nor  without  a  full  realization  of  the  gravity  involved.  This 
has  been  illustrated  by  Cases  205,  \\(\\  and  3U).2  These  three 
were  hereditary  cases  and  this  Fact  may  have  accounted  for  the 
long  duration  of  their  disease,  which  was  nine,  seven,  and  nineteen 

1  Christie:     Lor.  fit.,  |>.    \W. 

"Sec  Josiin:  Dialiclic  Standards,  Am.  Jour.  Mod.  Sr.,  101.3.  cxlv,  p.  474;  ;xlwo 
Konodirt  and  Josiin:  ( 'arneuie  Publication  No.  130,  1910,  pp.  1LS  and  120. 


CASES   UNSUCCESSFULLY   TREATED  BY  FASTING      359 

years  respectively.  They  finally  came  under  my  supervision  in 
a  much  debilitated  condition.  Even  at  that  time  the  danger  of 
changing  the  diet  was  appreciated,  and  unusual  care  was  taken  to 
prevent  a  fatal  issue.  The  3  cases  died  in  coma,  1  upon  a  sea 
voyage,  1  after  unusual  exertion,  and  1  for  reasons  unknown,  in 
periods  of  two  and  a  half  years,  two  months,  and  five  months, 
respectively,  after  being  seen.  Consequently,  when  Case  No.  887 
came  for  treatment,  with  a  duration  of  the  disease  of  twenty-nine 
years,  unusual  apprehension  was  felt.  For  nine  days  the  patient 
was  not  allowed  to  make  the  slightest  possible  change  in  the  regime, 
for,  although  she  was  wretched,  she  was  alive.  She  was  then  admitted 
to  the  hospital,  but  with  much  foreboding,  although  no  alarm  was 
felt  by  other  physicians,  experienced  in  diabetes,  who  saw  her.  Table 
1G1  shows  the  progress  of  the  patient. 

It  will  be  seen  that  fasting  for  nine  days  failed  to  rid  the  urine  of 
sugar;  indeed,  upon  the  ninth  day  the  quantity  of  dextrose  in  the 
urine  was  17  grams,  and  the  diet  contained  but  8  grams  of  alcohol. 
It  is  true  that  upon  the  second  day  after  admission  the  urine  was 
reported  as  sugar-free.  Acting  upon  this  supposition,  on  this  day 
5  per  cent,  vegetables  (150  grams)  were  allowed,  but  except  for  this 
day  fasting  was  complete  from  July  31  to  August  7.  On  August  8 
three  eggs  were  allowed;  on  August  9  three  eggs,  lean  meat  30 
grams;  on  August  10,  200  grams  of  orange,  about  15  grams  oat- 
meal and  the  whites  of  three  eggs,  but  otherwise  the  patient  took 
no  food  from  her  entrance  to  the  hospital  on  July  30  to  death  on 
August  12. 

March,  1917,  comment  on  Case  Xo.  887.  This  case  constitutes 
a  distinct  failure.  Contrast  the  treatment  of  this  case  with  that  of 
Case  Xo.  1151,  p.  171,  and  with  other  cases  cited  in  the  discussion 
of  the  treatment  of  Cases  Xos.  979  and  1007,  Tables  142  and  143. 

Table  101  shows  that  the  quantity  of  urine  varied  little  for  the 
first  five  of  the  thirteen  days.  From  then  on  it  increased  in  amount, 
and  it  is  here  again  significant  that  with  it  rose  the  nitrogen,  except 
upon  the  second  day  before  death.  With  the  increase  in  the  quan- 
tity of  urine,  there  was  an  increase  in  acidosis,  as  shown  by  the 
ammonia.  The  carbon  dioxide  tension  of  the  alveolar  air  did  not 
change  materially  during  the  whole  period,  for  it  was  32  mm.  Ilg 
upon  July  30,  and  29  mm.  Ilg  the  morning  of  August  11,  but  upon 
the  following  day,  shortly  preceding  death,  it  was  14  mm.  Ilg,  but 
an  estimation  made  at  this  time  may  not  have  been  wholly  reliable. 
The  inferences  which  were  drawn  from  the  behavior  of  the  alveolar 
air  were  misleading.  X'o  great  change  took  place  in  the  quantity 
of  sugar  excreted.  The  dextrose-nitrogen  ratio  at  the  beginning 
afforded  an  index  of  the  severity  of  the  disease,  though  this  state- 


3(>0 


TREATMENT 


r.(  i. )   'jn: 


•spiinocl 


-p;<l 


- 


-i  I+0+++T+1++1+ 


+  + 


CASES  UNSUCCESSFULLY  TREATED  BY  FASTING   301 

ment  cannot  be  made  without  qualification,  because  the  sugar  was 
estimated  by  rotation  instead  of  by  reduction.  Later  it  fell  for  two 
successive  days  as  the  quantity  of  ammonia  rose,  but  this  may  have 
been  related  to  the  changing  conditions  brought  about  by  the 
increasing  doses  of  sodium  bicarbonate. .  It  reached  to  3.73  :  1  the 
day  before  death.  There  are  two  other  features,  moreover,  which 
claim  attention:  first,  the  change  in  weight  of  the  patient  from 
132  pounds  to  122  pounds  in  ten  days,  and  the  low  excretion  of  salt. 
It  would  appear  that  the  loss  of  water  which  this  loss  of  weight 
represented  might  have  been  accompanied  by  a  washing  out  of  salt, 
but  the  analytical  data  do  not  support  this  view.  On  the  other 
hand,  there  was  an  increase  in  the  output  of  nitrogen.  This  would 
in  part  explain  the  lack  of  correspondence  between  the  dextrose- 
nitrogen  ratio  and  the  severity  of  the  disease,  although  at  the  same 
time  it  shows  that  the  mere  recording  of  the  dextrose-nitrogen 
ratio,  without  a  simultaneous  record  of  the  weight,  can  be  of  little 
significance. 

The  salt  was  not  determined  except  during  the  last  few  days  of 
life.  It  is  seen  that  in  tins  period  it  was  extremely  slight,  being 
respectively  4.3  grams,  2.8  grams,  and  4.0  grams.  These  low  figures 
suggest  that  during  the  preceding  ten  days  salt  was  being  lost  along 
with  body  fluid,  and  in  this  loss  of  weight  and  body  fluid  is  there  not 
an  explanation  of  the  untimely  death  of  the  patient?  The  admin- 
istration of  sodium  bicarbonate  temporarily  halted  the  progressive 
loss  of  body  weight.  When  one  compares  this  case  with  the  pre- 
ceding, the  suggestion  is  persistent  that  the  addition  of  large  quanti- 
ties of  salt  to  the  diet  might  have  led  to  the  retention  of  body  fluid 
and  interrupted  the  downward  course  of  the  patient.  A  study  of 
the  literature  shows,  as  has  been  pointed  out  in  an  earlier  article,1 
that  the  salt  in  the  urines  of  diabetic  patients  dying  in  coma  is 
unusually  low.  It  is  evident  that  they  need  salt,  and  efforts  should 
be  made  to  favor  the  retention  of  salt  and  water  by  severe  diabetics. 
The  retention  of  body  fluid  which  often  goes  hand  in  hand  with 
the  "oatmeal  cure,"  may  be  one  of  the  chief  advantages  which  have 
been  ascribed  to  that  "cure."  The  liberal  use  of  broths  during  the 
early  days  of  fasting  may  be  helpful  in  that  they  contain  considerable 
quantities  of  salt  and  prevent  loss  of  body  weight. 

The  patient  was  wretched,  it  is  true,  when  she  entered  the  hospital 
but  she  was  not  excessively  sveak.  With  a  gradual  elimination  of 
carbohydrate  following  the  omission  of  protein  she  might  have 
shown  a  moderately  large  tolerance  for  carbohydrate.  Plow  could 
she  have  done  otherwise  if  she  had  lived  for  twenty-nine  years  with 

1  Joslin  and  Goodall:  Experiments  on  an  Ash-free  Diet  and  Salt  Metabolism, 
Jour.  Am.  Med.  Assn.,  190b,  ii,  p.  727, 


:}(52  TREATMENT 

the  disease?  With  this  modification  of  dietetic  treatment  and  the 
omission  of  alkalis  I  should  not  anticipate  a  like  catastrophe  with  a 
similar  patient  today. 

1.  Cardiorenal  Complications. — Cardiorenal  complications  can 
easily  lead  to  the  death  of  patients  with  diabetes.  It  is  not,  there- 
fore, surprising  that  one1  such  death  occurred  among  those  treated 
with  fasting.  The  patient  in  question  had  a  high  blood-pressure, 
mitral  insufficiency  and  a  history  of  Gra yes's  disease.  The  detailed 
record  of  the  case  is  as  follows: 

Case  No.  X(59.  Female,  aged  forty-six  years.  Came  under 
observation  August  2,  191 5.  Although  sugar  was  reported  absent 
in  January,  1915,  its  presence  was  discovered  May  22,  1915.  The 
symptoms  pointed  to  the  onset  in  May,  1913.  Weight,  June  4, 
1915,  l))4-4-  pounds.  Xo  acetone  odor  to  the  breath,  thyroid  moder- 
ately enlarged,  pulse  120,  blood-pressure  1(50,  with  a  previous  record 
of  190,  as  was  later  learned  from  another  physician.  The  diffuse 
and  feeble  apex  beat  of  the  heart  was  in  the  sixth  space  outside  the 
mammillary  line,  and  accompanied  by  a  systolic  murmur  widely 
transmitted.  The  liver  was  palpable  one  fingerbreadth  below  the 
costal  margin  ('Fable  1(52). 

The  chart  shows  that  on  June  1  there  was  4  per  cent,  of  sugar  in 
the  urine,  and  that  this  decreased  to  2. (5  per  cent,  and  1.4  per  cent. 
respectively  within  two  days  after  entrance  to  the  hospital,  and  on 
the  following  day  disappeared  and  remained  absent,  except  for 
0.2  per  cent,  during  the  last  twenty-four  hours.  On  the  other  hand, 
with  the  institution  of  fasting,  acidosis  appeared  and  increased,  but 
never  exceeded  that  degree  represented  by  1.S7  grams  of  ammonia 
in  the  twenty-four  hours.  The  ferric  chloride  reaction,  however, 
increased  in  intensity  and  the  urinary  sediment  directly  after 
entrance  showed  a  few  hyalin  casts  and  granular  casts.  It  is 
regrettable  that  other  tests  for  acidosis  were  not  employed,  par- 
ticularly in  a  case  of  this  type  in  which  retention  of  acid  bodies 
might  well  have  taken  place. 

Vomiting  began  four  days  after  admission  and  persisted  until 
death  the  same  day.  The  patient  did  not  become  unconscious,  but 
undoubtedly  succumbed  to  a  relatively  mild  acid  poisoning— incom- 
plete coma.  It  has  been  pointed  out  elsewhere  that  a  moderate- 
degree  of  acid  poisoning  may  cause  the  death  of  a  patient,  previously 
free  from  acid  poisoning,  whereas  acid  poisoning  of  a  severe  char- 
acter may  be  borne  for  years  by  a  diabetic  patient  in  whom  it 
has  gradually  developed.  Furthermore,  acid  poisoning  in  a  diabetic 
with  impaired  kidneys  is  also  serious. 

Rapid  changes  in  weight  must  have  taken  place  in  this  patient 
too,  just  as  in  Case  Xo.  513,  described  under  Infections,  and  Case 


CASES   UNSUCCESSFULLY   TREATED  BY  FASTING       3G3 


" 
o 
O 


'COOIIT!X     °     ° 


•SI1I3    '0.)Ut7 


.  i 


I  + 


a 


O 


o 


3f>4  TREATMENT 

Xo.  SS7,  described  under  Diabetes  of  Long  Duration.  This  is 
evident,  because  the  patient  retained  no  food  for  many  hours  and 
yet  voided  during  this  period  at  least  2000  c.c.  urine. 

March,  1017,  comment  upon  Case  Xo.  8f>9.  The  cardiorenal 
condition  was  quite  as  severe  as  the  diabetes.  By  treatment  the 
diabetes  ought  to  have  been  improved,  not  made  worse.  The  patient 
entered  the  hospital  without  acidosis  and  should  have  left  without 
its  development.  The  omission  of  fat  followed  by  the  cautious 
restriction  of  carbohydrate  and  protein  would  have  rendered  this 
possible.  By  the  stay  in  the  hospital  both  the  diabetes  and  the  heart 
disease  should  have  been  benefited. 

5.  Syphilis. — The  treatment  of  syphilis  may  have  been  responsible 
for  the  deatli  of  one  patient,  but  changes  in  diet  very  likely  were  an 
equal  factor.  Case  Xo.  S0(i,  male,  aged  thirty-eight  years,  came 
under  observation  December  17,  1914,  reporting  an  onset  of  diabetes 
two  months  before.  The  urine  contained  7.8  per  cent,  sugar,  but 
after  two  days'  fasting  glycosuria  disappeared.  The  tolerance 
gradually  rose  to  -4  grams  carbohydrate,  50  grams  protein,  and 
enough  fat  to  maintain  Aveight.  Following  discharge,  the  patient 
remained  in  good  condition  under  the  observation  of  his  physician, 
and,  so  far  as  1  can  learn,  was  sugar-free.  In  June,  1915,  I  heard 
from  his  physician  that  another  doctor  had  obtained  a  positive 
Wassermann  reaction,  that  three  injections  of  salvarsan  had  been 
given,  and  mercury  and  iodide  of  potash  as  well.  Shortly  after, 
the  patient  became  suddenly  ill  and  died  in  coma. 

March,  1917,  comment  upon  Case  Xo.  800.  The  possibility  of 
syphilis  should  have  been  proved  or  disproved  when  the  patient  was 
first  seen  and  the  proper  treatment  of  the  syphilis  instituted  under 
the  favorable  surroundings  of  the  hospital. 

H.     SPECIAL  DIETETIC  METHODS. 

1.  Fasting  Days. — Looking  back  upon  the  treatment  of  diabetes 
prior  to  Allen's  introduction  of  prolonged  fasting,  it  really  seems, 
to  use  an  expression  of  Xaunyn's  in  reference  to  the  care  of  severe 
cases,  that  our  diabetic,  patients  were  nursed  rather  than  treated. 
Only  those  who  have  cared  for  many  patients  by  the  older  methods 
can  appreciate  the  advance  which  Allen  has  given  to  diabetic 
therapy.  Many  years  ago  Xaunyn  strongly  urged  the  use  of 
starvation  days  in  the  treatment  of  diabetes.  lie  repeatedly 
called  attention  to  the  advantages  derived  therefrom,  and  said  one 
should  not  fear  temporary  undernutrition  if  thereby  it  was  possible 
to  remove  the  sugar  from  the  urine.  Over  and  over  again  a  day  of 


SPECIAL   DIETETIC   METHODS  305 

starvation  would  render  a  patient  sugar-free  when  all  else  had  failed. 
Such  days  were  usually  indicated  in  the  treatment  of  the  severest 
cases  of  diabetes,  and  in  a  case  of  moderate  severity  such  a  day 
would  do  what  many  days  of  low  diet  had  failed  to  accomplish. 
But  it  was  not  alone  to  render  the  urine  free  from  sugar  and  to  place 
the  patient  in  a  better  condition  to  acquire  tolerance  for  carbo- 
hydrates that  Xaunyn  used  these  days,  for  he  observed  that  they 
helped  to  lower  the  acidosis  in  a  striking  manner.  Von  Xoorden 
agreed  with  Xaunyn  that  these  days  were  never  disadvantageous. 
lie  writes:  "I  make  use  of  these,  especially  when  there  is  high 
acetonuria.  It  is  astonishing  how  strikingly  the  acetone  falls  on 
a  hunger  day.  Its  effect  stretches  out  for  a  number  of  days  later. 
In  numerous  severe  cases  a  hunger  day  has  been  instituted  every 
week  with  excellent  results."  A  third  reason  existed  which  also 
accounted  for  the  good  effects  of  a  starvation  day,  to  wit:  the 
patient's  digestion  was  given  a  rest.  X'aunyn,  in  an  indirect  way, 
protected  the  digestion  of  his  patients  by  emphasizing  the  value  of  a 
low  caloric  intake.  Hodgson,  too,  is  precise  upon  this  point.  He 
says:  "Again  it  should  be  stated  that  the  quantity  of  all  food,  even 
if  it  is  carbohydrate-free,  must  be  greatly  restricted.  The  number  of 
calories  that  the  body  ordinarily  requires  is  no  safe  criterion  of  the 
amount  of  food  that  should  be  given  a  diabetic.  It  is  not  the 
quantity  of  food  that  should  be  metabolized,  but  the  amount  that 
can  be  metabolized  that  should  determine  the  amount  given  to  the 
patient.  All  in  excess  of  what  a  patient  can  actually  use  burdens 
the  already  overtaxed  excretory  organs  and  retards  improvement." 

Hodgson  should  be  given  the  credit  of  having  published  this 
article  in  191 1.1  Guelpa,  in  1910,2  reported  his  success  in  the  treat- 
ment of  diabetes  by  the  employment  of  several  days'  fasting  com- 
bined with  purgation:  "I  do  not  pretend  that  this  cure  has  been 
put  as  yet  on  a  definite  scientific  basis.  Much  further  and  more 
generalized  experience  of  it  is  required  before  we  can  arrive  at 
clear  conclusions  as  to  the  extent  of  its  sphere  of  usefulness.  From 
the  observations  I  have  already  made,  however,  of  the  action  of  the 
cure,  it  is  possible  to  draw  certain  inferences  of  capital  importance. 

"1.  There  is  absolutely  no  danger  and  no  serious  inconvenience 
in  abstaining  entirely  from  food  for  three  or  four  days,  or  even 
longer;  the  period  of  abstinence,  also,  may  be  repeated  several 
times  without  risk  or  inconvenience,  if  each  day  a  large  dose  of  a 
purgative  is  given  to  insure  intestinal  disinfection. 

"  2.  While  there  may  be  some  slight  discomforts  during  the  period 
of  abstinence,  these  never  persist  after  food  is  resumed.  On  the 
other  hand,  undoubted  and  durable  benefits  are  always  gained,  in 

1  Hodgson:   Jour.  Am.   Mecl.  Assn..   1911,  Ivii,  p.  1187. 
=  Guelpa:  British  Mod.  Jour.,   1910.  ii,  p.  1050. 


36()  THE  ATM  EXT 

the  shape  of  increased  freedom  of  movement,  greater  clearness  of 
ideas,  amelioration  of  all  congestive  conditions,  and  a  true  feeling 
of  general  well-being.  In  a  word,  one  is  always  better  in  all  respects 
after  the  cure  than  before. 

".'!.  The  cure  is  a  perfectly  safe  procedure  if  controlled  by  exami- 
nations of  the  blood  and  the  urine.  It  insures  the  maximum  of 
benefit  being  derived  from  any  concomitant  therapeutic  measures." 

(iiielpa  reports  many  cases  of  diabetes  and  the  astonishingly  good 
results  which  followed  the  method  he  employed.  He  deserves 
great  credit  for  his  originality  and  courage  in  applying  this  method 
as  well  as  for  his  modesty,  and  his  name  should  always  receive  a 
prominent  place  when  fasting  is  mentioned. 

The  advantages  of  the  fasting  method  at  the  outset  of  treatment 
are  many:  (1)  It  is  a  simple  method  and  enables  the  practising 
physician  to  render  all  save  exceptional  cases  of  diabetes  sugar- 
free  and  to  keep  them  so.  (2)  The  treatment  is  such  that  acidosis 
is  almost  invariably  diminished  rather  than  increased.  How  much 
such  a  gain  in  treatment  means  is  plain  when  one  remembers 
how  large  a  percentage  of  the  fatalities  of  diabetes  during  the  first 
twelve  months  of  the  disease  is  due  to  coma.  Furthermore,  should 
acid  poisoning  occur  in  the  course  of  treatment,  fasting  will  almost 
invariably  lessen  and  eventually  dispel  it.  In  consequence,  alkalis 
have  become  seldom,  if  ever,  necessary.  (.'>)  The  method  is  suit- 
able for  a  patient  to  learn,  and  he  is  thereby  placed  in  a  position  to 
protect  himself.  (4)  The  expense  of  treatment  to  the  patient  is 
reduced  because  he  can  readily  perform  the  urinary  tests  essential 
for  treatment,  and  by  keeping  sugar-free,  visits  to  a  physician 
are  rendered  infrequent.  (5)  The  responsibility  of  treatment  rests 
upon  the  patient,  and  this  makes  the  chances  of  his  following  direc- 
tions far  more  probable.  But  the  most  satisfactory  part  of  fasting 
treatment  is  the  sound  basis  upon  which  it  is  founded.  Others  have 
employed  and  advised  fasting;  Xauuyn  and  (iuelpa  tried  it  exten- 
sively; Hodgson  used  a  very  low  diet  with  great  success,  but  Allen 
}>rnml  prolonged  faxtiny  efficacious.  Before  hr  treated  ani/  human 
jtaftentx  hi/  faxting,  lie  demonstrated  that  flux  method  icax  iixefnl  for 
animal*.  To  accomplish  this  he  performed  partial  pancreatectomy 
in  dogs,  preserving  that  portion  of  the  pancreas  adjoining  the  duct, 
so  as  to  avoid  atrophy  of  the  remnant.  Allen  found  that,  according 
to  the  amount  of  pancreas  removed,  simple  lowering  of  the  sugar 
tolerance  without  actual  diabetes  results,  or  a  diabetes  varying  in 
intensity  from  the  mildest  to  the  very  severest  type  can  be  produced. 
Ivcstriction  of  carbohydrate  or  protein,  or  brief  fasting,  would 
render  animals  with  the  mild  type  sugar-free,  but  to  accomplish 
this  with  the  animals  of  the  severest  type  fasting  must  be  prolonged 
for  many  days  or  even  weeks.  Eventually,  however,  it  could  be 


SPECIAL   DIETETIC   METHODS  367 

successful,  and  along  with  the  disappearance  of  the  sugar,  acidosis 
would  also  pass  away.  Allen's  experience  convinced  him  that  the 
glycosuria  of  even  the  severest  type  of  diabetes  might  be  cleared  up 
advantageously  by  one  initial  fast,  though  it  might  be  necessary 
to  prolong  it  exceptionally  for  eight  or  ten  days.  And  he  goes  on 
to  say:  "Broadly  speaking,  freedom  from  glycosuria  seems  obtain- 
able in  all  cases  of  uncomplicated  human  diabetes  before  there  is 
danger  of  death  from  starvation.  Even  wasted  and  emaciated 
patients  have  borne  fasting  with  apparent  benefit,  giving  the  impres- 
sion that  they  have  been  suffering  more  from  intoxication  than 
from  a  lack  of  nutrition;"  and  in  another  place,  "  among  the  patients 
treated  thus  far  during  a  variable  number  of  months,  in  the  hospital 
and  at  home,  spontaneous  downward  progress  has  not  yet  been 
observed."  Today  I  doubt  if  he  would  feel  justified  in  making 
quite  so  strong  a  statement,  but  certainly  it  is  true  that  downward 
progress  where  the  patient  is  under  a  careful  regime  is  far  less 
common  than  hitherto,  and  I  feel  more  like  agreeing  with  Allen 
today  than  a  year  ago. 

2.  Vegetable  Days. — "Vegetable"  days  or  "green"  days —  "rab- 
bit" or  "  Nebuchadnezzar"  days  as  the  patients  sometimes  call  them 
— were  suggested  by  von  Noorden  as  useful  and  less  exacting  than 
fasting  days  in  the  course  of   diabetic  treatment.      Their  intro- 
duction was  of  much  value,  because  many  physicians  would  pre- 
scribe vegetable  days  who  were  afraid  to  order  a  fasting  day,  and 
many  patients  would  take  a  vegetable  day  who  refused  to  go  entirely 
without  food.     The  sense  of  satisfaction  which  one  obtains  from 
the  bulk  of  vegetables  is  far  out  of  proportion  to  the  little  nutri- 
ment contained.    Unfortunately,  in  the  use  of  vegetable  days,  large 
quantities  of  fat  were   often  employed,   and  the  benefits  which 
might  have  been  derived  therefrom  were  to  a  considerable  extent 
counteracted.     So  employed,  a  vegetable  day,  instead  of  being  a 
day  of  undernutrition  with  a  small  amount  of  carbohydrate  which 
would  have  favored  the  lowering  of  acidosis,  became  in  reality  a 
fat  day,  and  in  consequence  the  acidosis  did  not  always  decrease. 
Today   vegetable   days   are   employed   without   fat   to   lessen   the 
acidosis,  and  probably  with  justification. 

3.  The  Oatmeal  Treatment. — The  use  of  oatmeal  as  a  special 
form  of  treatment  in  diabetes  was  introduced  by  von  Xoorden  in 
1903. l    The  sudden  disappearance  of  sugar  from  the  urine,  despite 
the  administration  of  so  much  carbohydrate,  was  at  first  looked 
upon  with  awe.      Gradually  with  a  better  understanding  of  the 
storage  of  carbohydrate  in  the  body  and  its  utilization  or  non- 
utilization,  as  disclosed  by  the  respiratory  quotient,  the  mystery 

'Von  Noorden:  Bcrl.  klin.  Wohnschr.,  1903,  xl,  p.  817. 


3C.S 


TREATMENT 


began  to  disappear.  The  actual  "cure"  is  seldom  employed  today, 
but  the  experimental  problems  associated  with  it  are  so  many  that 
it  deserves  extended  discussion.  Formerly  I  occasionally  employed 
it  in  the  treatment  of  very  severe  cases  of  diabetes,  but  the  apparent 
lack  of  the  utilization  of  oatmeal  as  disclosed  by  the  respiratory 
quotient  discouraged  extensive  use  of  the  same.  Notwithstanding 
this  fact,  and  although  1  have  not  treated  a  ease  in  this  manner  for 
over  two  years,  I  believe  the  oatmeal  treatment  has  taught  us  much, 
and  that  eventually  we  shall  benefit  by  the  new  idea  it  introduced. 

The  "cure"  was  originally  prescribed  by  von  Xoorden1  as  follows: 
"The  oat  c.ure,  as  now  prescribed  by  me,  consists  in  the  daily 
administration  of  200  to  250  grams  of  oatmeal,  best  given  in  the 
form  of  gruel  every  two  hours,  and  200  to  '500  grams  of  butter, 
and  often  about  100  grams  of  vegetable  proteid  or  a  few  eggs  may 
be  taken  in  addition.  Otherwise,  nothing  else  is  allowed,  except 
black  coffee,  or  tea,  lemon  juice,  good  old  wine,  or  a  little  brandy  or 
whisky.  Such  a  diet  is  often  disliked  by  the  patient,  but  I  have 
ahvays  succeeded  in  getting  over  this  difficulty.  After  three  or 
four  days  upon  it  the  purpose  for  which  it  was  intended  is  often 
found  to  have  been  attained;  in  other  cases  the  same  program  must 
be  repeated  two  or  three  times.  It  is  apparently  advisable  to 
precede  the  oat  cure  with  a  few  days  of  restricted  diet,  or  even  one 
or  two  vegetable  days,  for  when  the  cure  immediately  supervenes 
upon  a  mixed  diet  the  desired  effect  follows  rather  late. 

TABLE   103. — 'Vox  NOORDEX'S  ILLUSTRATION"  OF  THE  "()AT  CUKE." 


Diet. 

1.  Strict  diet 

2.  Strict  diet 
.'i.  Strict  diet 

4.  Vegetable  day 
fj.  Vegetable  day 
().  <  >at  meal  ( 

7.  ( )at  meal 

5.  Oatmeal 
(t.  Oatmeal 

0.  Veiietabli 

1.  Vegetal, 1. 
•2.  Oatmeal 
:;.  Oatmeal 
1.  Oatmeal 
:>.  Vegetable 


f  + 


Ammonia, 
Kins. 

3.2 

3.8 
4.15 
2.9 
2.8 
2.1 
1.0 
1  .5 
1  .1 
1  .:; 
l.s 
0.9 
().(.) 
1.0 
0.8 

o.s 

0.7 
1  .0 
0.9 
0.8 


"At  the  commencement  of  the  oat-cure  treatment  one  notices, 
it   is  true,   even   in   the   most   favorable  cases,   an   increase  of  the 


Von  Nnnrden: 


I).  H.  Treat  &  Co.,  1900,  p.   190, 


SPECIAL  DIETETIC  METHODS  309 

glycosuria;  but  after  a  few  days  the  excretion  of  sugar  diminishes 
and  the  acetonuria  even  more  so.  During  the  oat  days  the  urine 
may  often  be  quite  free  from  sugar,  and  if  it  is  not  entirely  free, 
one  may  be  fairly  certain  that  it  will  be  so  in  the  succeeding  vegetable 
days.  Table  103  gives  the  details  of  one  such  favorable  case. 

"The  estimations  made  before  the  oat  cure  was  begun  show 
plainly  enough  that  it  is  a  case  of  severe  glycosuria  combined  with 
excessive  acetonuria.  With  the  most  restricted  diet  it  had  not  been 
possible  to  bring  the  sugar  below  40  grams;  even  on  vegetable  days 
more  than  20  grams  were  excreted.  In  the  course  of  the  oatmeal 
treatment  the  urine  became  free  from  sugar,  and  it  remained  so  on 
the  subsequent  return  to  the  restricted  diet.  It  even  appeared  that 
small  quantities  of  carbohydrate  could  be  well  tolerated,  whereas 
for  several  months  previously  there  had  been  no  question  of  such  a 
thing.1 

"I  believe  that  a  glance  at  Table  103,  which  is  only  one  out  of  a 
large  number  showing  the  same  thing,  will  suffice  to  show  that  a 
result  has  accrued  which  formerly  would  have  been  deemed  impos- 
sible to  obtain.  Unfortunately,  however,  there  are  only  relatively 
few  cases  in  which  the  result  is  quite  so  surprisingly  beneficial; 
in  many  others  it  is  incomplete,  although  still  satisfactory;  in 
others  again  no  result  at  all  is  obtained.  The  following  fact  is 
noteworthy:  cases  in  which  the  results  of  the  treatment  were  most 
beneficial  relate  without  exception  to  the  very  severe  forms  of 
glycosuria;  many  of  them  were  in  children  or  young  people.  On 
the  other  hand,  the  result  was  almost  without  exception  a  failure 
in  cases  of  slight  glycosuria,  the  exact  opposite  of  what  might 
a  priori  have  been  expected.2  The  oat  cure  rendered  me  immense 
service  in  severe  cases,  and  I  may  even  say  that  I  have  often  suc- 
ceeded in  fending  off  incipient  coma  by  its  use." 

The  positive  proof  of  the  value  of  an  oatmeal  day  \vould  be  the 
demonstration  that  the  carbohydrate  in  the  oatmeal  was  oxidized 
in  the  body.  As  yet,  such  a  proof  has  not  been  satisfactorily  estab- 
lished. It  does  not  suffice  to  show  that  the  sugar  represented  by  the 
oatmeal  does  not  appear  in  the  urine  during  the  oatmeal  period. 
One  should  demonstrate  a  rise  of  the  respiratory  quotient  following 
the  use  of  oatmeal.  This  would  appear  an  easy  problem.  Thus 
my  own  respiratory  quotient  before  breakfast  on  September  30, 
1914,  was  0.82,  but  forty-five  minutes  later,  after  I  had  eaten  00 
grams  carbohydrate  in  the  form  of  oatmeal  it  rose  to  0.90.  With  dia- 
betic patients  the  results  were  irregular  but  the  evidence  on  the  whole 

1  From  the  data  furnished  in  Table  163,  this  case  would  not  appear  severe  today. 
This  may  be  one  reason  why  the  improvement  was  so  marked. 

2  Perhaps  the  mild  cases  were  not  as  energetically  fasted  beforehand  as  were  the 
severe. 

24 


370  THE  ATM  EXT 

suggested  a  slight  utilization.  These  are  reported  in  detail  in  Section 
1 1 .  Benedict  and  I  have  found  the  problem  most  difficult  and  so  have 
other  investigators.  Roily  in  a  series  of  experiments  tested  the  com- 
parative effects  of  oats,  rye,  wheat,  lentils,  and  green  cornmeal  on 
diabetic  patients.  Unfortunately,  few  of  the  experiments  were  pre- 
ceded by  control  periods.  Two  of 'his  cases  lie  considers  severe.  In 
Case  I,  at  three,  five,  and  six  hours  after  70  grams  of  oatmeal  were 
administered,  the  respiratory  quotient  was  0.73.  After  70  grams  of 
wheat  meal  it  was  0.76.  The  respiratory  quotient  of  his  Case  V  after 
SO  grams  of  wheat  meal  was  0.71,  after  SO  grams  of  rye  mealwas().73, 
and  after  SO  grams  of  oatmeal  was  0.71 .  \Ve  have  repeatedly  failed  to 
find  any  increase  in  the  respiratory  quotient  immediately  after  con- 
siderable quantities  of  oatmeal  were  ingested.  (See  Cases  Xos.  194, 
'2 K't.  332,  ")(')  1 ,  591 ,  740  and  773.)  We  soon  felt  that  experiments  of  a 
few  hours'  duration  could  not  be  decisive,  for  the  oatmeal  might 
be  simply  stored  in  the  body  and  later  oxidi/ed.  The  length  of 
the  experiments  was  therefore  extended  to  twenty-four  hours,  but 
even  then  the  oxidation  of  oatmeal  was  not  satisfactorily  proven 
by  the  rise  in  the  quotient.  Again  our  experiments  were  lengthened 
and  by  means  of  the  respiratory  apparatus  a  series  of  some  eight 
observations  was  made  daily  upon  two  cases  during  two  oatmeal 
days,  but  here,  too,  no  consistent  effect  from  tlie  oatmeal  was  demon- 
strated. Such  a  series,  however,  is  not  complete,  and  the  fasting 
quotient  was  determined  on  the  morning  of  the  third  day  with 
the  result  that  in  this  case  (Case  No.  501)  it  was  0.70.  These 
data  are  all  recorded  in  the  charts  on  page  145.  It  is  very  clear 
that  much  work  must  be  done  before  decisive  conclusions  upon  the 
utilization  of  oatmeal  in  diabetes  are  reached.  The  introduction 
of  fasting  treatment  will  simplify  the  problem  by  furnishing  a 
method  by  which  the  patients  can  be  placed  in  a  more  stable  state 
of  equilibrium  prior  to  the  test  \vith  the  oatmeal. 

Allen  and  DuBois1  in  studies  upon  several  severe  diabetics  find 
"no  special  influence  of  oatmeal  in  diabetes  or  special  readiness  of 
oxidation.  .  .  .  The  respiratory  exchange  fails  to  account  for 
all  the  carbohydrate  that  disappears.  The  behavior  of  the  respira- 
tory quotient  showed  no  important  difference  on  the  first  day  and 
on  the  third  day  of  the  oatmeal  treatment." 

In  the  light  of  present  knowledge  the  frequently  striking  suc- 
cesses of  the  oatmeal  treatment  in  diabetes  as  practised  during  the 
last  few  years  are  seen  to  depend  upon  several  factors  of  which 
the  most  important  is  the  fasting  or  greatly  restricted  diet  which 
preceded  and  followed  the  cure.  A  similar  result  could  be  obtained 
with  any  carbohydrate  as  Blum  pointed  out  and  as  Klemperer's 

'Allen  and  DuBoib:    Arch.  Int.  Mcd.,  1010,  xvii,  p.  1010. 


SPECIAL   DIETETIC   METHODS  371 

experiments  with  dextrose  and  Benedict's  and  my  experiments  with 
levulose  show.  During  fasting  the  sugar  level  in  the  body  is  lowered 
and  the  body  is  therefore  in  a  more  favorable  condition  to  store 
carbohydrate  and  possibly  to  utilize  it  than  under  ordinary  circum- 
stances. The  fasting  or  semifasting  which  followed  the  oatmeal 
days  may  be  of  very  great  advantage.  It  is  quite  possible  that 
carbohydrates  stored  for  a  long  period  in  the  body  may  ultimately 
be  better  oxidized  than  carbohydrates  representing  more  nearly  an 
overflow  of  the  carbohydate  reservoir  which  escape  quickly  into  the 
urine.  With  this  in  mind  it  is  easy  to  understand  why  Blum  found 
small  quantities  of  oatmeal  worked  better  than  large  amounts  in 
severe  diabetics.  He  also  showed  it  was  more  successful  in  mild 
than  in  severe  cases. 

Yon  Xoorden  also  made  another  observation  which  indicates  that 
the  oatmeal  is  simply  stored.  A  patient  showed  no  sugar  during 
the  two  preliminary  vegetable  days  and  the  three  following  oat- 
meal days,  yet  in  the  next  three  vegetable  days  96,  100  and  32 
grams  of  sugar  were  excreted  respectively. 

The  quantity  of  protein  upon  the  oatmeal  days  is  extremely  slight. 
Thus,  whereas  the  carelessly  treated  patient  in  diabetes  ordinarily 
consumes  far  more  than  100  grams  of  protein,  if  he  takes  even  the 
full  quantity  of  oatmeal,  namely,  250  grams,  he  will  receive  not 
over  40  grams.  The  low  quantity  of  protein  is  undoubtedly  an 
important  factor  in  the  success  of  the  treatment. 

The  oatmeal  is  given  without  animal  protein.  It  has  been  thought 
that  animal  protein  is  somewhat  less  well  borne  by  diabetic  patients 
than  vegetable  protein,  but  I  do  not  believe  the  evidence  hitherto 
submitted  to  be  convincing.  The  difference  in  the  rate  of  absorption 
of  the  two  kinds  of  protein  may  be  of  importance. 

Interesting  observations  bearing  upon  this  point  were  found  in 
the  literature  by  F.  M.  Allen  in  the  experiment  of  Kichhorst,1  who 
showed  that  dogs  fed  on  nothing  but  starch  gruel  for  a  considerable 
period  and  then  suddenly  given  a  large  quantity  of  meat  show 
glycosuria  on  the  first  or  second  day  of  meat  feeding,  but  not 
thereafter.  Five  of  Eichhorst's  dogs  behaved  thus,  and  the  glyco- 
suria resulting  from  meat  diet  ran  even  above  2  per  cent.  Straub 
and  Rosenstein  found  that  preliminary  meat  feeding  favored  the 
occurrence  of  glycosuria  in  animals  poisoned  with  carbon  monoxide, 
but  this  did  not  take  place  if  the  animals  were  previously  fed  with 
pure  carbohydrate,  or  abundant  carbohydrate  with  little  protein. 
Similarly,  Selig  noted  that  ether  anesthesia  was  followed  by  glyco- 
suria in  dogs  fed  with  meat,  but  that  it  did  not  appear  with  a  pre- 
liminary feeding  of  carbohydrate.  In  his  study  of  the  oatmeal 

1  For  this  and  other  references  in  this  paragraph,  see  Allen:  Glycosuria  and  Dia- 
betes, 1913,  p.  441. 


372  TREATMENT 

treatment,  Fulta  observed  tnat  ])rotein  added  to  the  oatmetd 
treatment  tended  to  the  excretion  of  more  sugar  in  the  urine 
than  could  come  theoretically  from  the  added  protein,  and  that 
meat  was  especially  harmful  as  compared  with  vegetable  protein. 
Indeed,  some  patients  were  more  sensitive  to  protein  than  to  car- 
bohydrate. 

In  a  recent  publication,  Bernstein  and  Falta1  have  shown  that  a 
carbohydrate-fat  diet  lowers  the  metabolism,  and  they  explain 
this  as  a  result  of  the  attendant  decreased  protein  metabolism.  A 
lowering  of  the  metabolism  is  therefore,  according  to  them,  to  be 
expected  in  the  oatmeal  treatment,  because  of  the  small  quantity 
of  protein  therein  contained.  This  has  been  observed,  but  they  point 
out  that  such  a  lowering  is  to  be  expected  only  when  the  carbo- 
hydrate is  utilized  and  thereby  body  protein  spared.  Their  data 
are  most  interesting.  I  am  not  ready  to  draw  conclusions  from 
Benedict's  and  my  own  experiments  upon  this  same  topic  as  yet, 
but  I  would  point  out  that  invariably  in  our  levulosc  experiments 
the  metabolism  rose  after  levulose  (see  pp.  3XO-3S4).  The  article  of 
Bernstein  and  Falta  is  of  much  value,  and  I  recommend  its  perusal 
not  the  less  because  of  the  criticisms  it  contains  upon  Benedict's  and 
my  work.  These  criticisms  will  receive  careful  analysis  in  our  forth- 
coming ( 'arnegie  publication. 

A  gain  in  weight  is  usually  coincident  with  the  employment  01 
the  oatmeal  cure.  This  is  not  peculiar  to  oatmeal,  and  is  said  to 
occur  as  a  result  of  any  carbohydrate  day,  though  I  now  have  some 
doubt  as  to  the  accuracy  of  this  statement.  Already  attention  has 
been  called  to  this  phenomenon  of  gain  in  weight  on  changing  from  a 
fat  to  a  carbohydrate  diet  in  normal  individuals.  Contrary  to  many 
observers,  who  have  considered  it  a  disadvantage  that  the  patient 
develops  edema,  in  most  cases  I  think  it  is  distinctly  helpful.  I 
cannot  forget  that  patients  with  edema  seldom  or  never  develop 
diabetic  coma.  Falta  noted  a  remarkable  retention  of  protein 
during  the  oatmeal  cure.  The  significance  of  this  has  not  been 
explained,  but  it  is  probably  in  some  way  connected  with  the  reten- 
tion of  fluids  by  the  body.  A  second  explanation  of  the  gain  in 
weight  may  be  the  behavior  of  the  kidneys,  according  to  Barren- 
scheen.  Tie  injected  human  subjects  intravenously  with  '20  c.c.  of  a 
10  per  cent,  solution  of  lactose,  and  upon  each  of  the  following  two 
days  he  gave  2.~>0  grams  oatmeal.  On  the  third  day  he  gave  a  mixed 
diet,  together  with  a  repetition  of  the  injection.  Ipon  the  oatmeal 
days  the  excretion  of  the  lactose*  was  delayed  from  one  to  five  hours, 
which  Barrenscheen  attributed  to  slight  renal  changes,  not  otherwise 
demonstrable,  caused  by  the  oatmeal.  A  third  reason  for  the  gain 

'Bernstein  and  Falta:    Doutsch.  Archiv  f.  klin.  Mod.,  1910,  cxxi,  p.  95. 


SPECIAL  DIETETIC  METHODS  373 

in  weight  may  be  the  high  caloric  value  of  an  oatmeal  day.     This 
is  not  generally  appreciated.    It  is  shown  in  Table  164. 

TABLE  1G4. — NUTRITIVE  VALUE  OF  AN  OATMEAL  DAY. 

Carbo 

Substance.                     Quantity.       hydrate.  Protein.          Fat.  Alcohol.  Calories. 

Oatmeal       ...      240              100  40                10  .  .                944 

Butter    ....      240              ...  .  .  200  .  .  LSOO 

Whisky        ...        GO              ...  .  .  ...  30                210 


Total        ....      160  40  21(3  30  2954 

A  fourth  cause  of  gain  in  weight  upon  an  oatmeal  day  is  the 
considerable  quantity  of  salt  taken  by  the  patient.  For  example, 
in  the  preparation  of  240  grams  of  oatmeal  the  usual  quantity  of 
salt  added  by  the  cook  is  10  grams  and  the  patient  may  take  even 
more.  If  to  the  oatmeal  an  equal  amount  of  butter  is  added, 
according  to  the  original  advice  of  von  Xoorden,  the  quantity  of 
salt  is  increased  by  0.3  grams,  for  butter  contains  on  the  average 
2.51  per  cent.  salt.  It  would  therefore  seem  quite  likely  that  the 
edema  which  is  associated  with  the  oatmeal  treatment  might  in 
great  part  be  explained  by  the  unusual  quantity  of  salt  given  upon 
that  day,  and  it  is  conceivable  that  along  with  the  salt  a  considerable 
quantity  of  the  carbohydrate  of  the  oatmeal  might  be  retained  as  well. 

A  striking  characteristic  of  the  oatmeal  treatment  is  that  car- 
bohydrate is  administered  in  only  one  form  and  it  has  been  con- 
tended that  this  is  one  reason  for  its  apparently  better  assimilation 
than  the  same  amount  of  carbohydrate  in  several  forms.  This 
supposition  may  be  true  but  there  is  little  sound  evidence  behind 
it.  Such  a  phenomenon  might  be  explained  by  the  simplicity  and 
blandness  of  such  a  diet  leading  to  very  slight  stimulation  of  the 
digestive  glands  in  general,  and  the  pancreas  in  particular.  In 
fact  Cohnheim  and  Klee  have  noted  this  peculiarity  in  oatmeal. 
This  may  explain  why  boiled  oatmeal  acts  better  than  baked  oat- 
meal. Allen  has  pointed  out  that  if  the  external  function  of  the 
pancreas  is  relieved  of  work  the  internal  function  may  act  more 
vigorously  and  the  diabetic  condition  be  correspondingly  benefited. 
The  explanation  agrees  with  facts.  Allen  cites  the  work  of  Cohn- 
heim  and  Klee,  who  observed  that  the  foods  which  caused  the 
greatest  activity  of  the  external  pancreatic  function  are  the  ones 
which  give  rise  to  glycosuria,  and  the  foods  which  stimulate  the 
external  pancreatic  function  least  are  the  ones  which  have  least 
tendency  to  glycosuria.  These  writers  suggest  that  the  internal 
function  of  the  pancreas  is  strengthened  by  relieving  the  strain 
upon  the  external  function. 

Various  other  theories  have  been  put  forth  to  explain  the  oatmeal 
"cure,"  but  none  have  been  entirely  satisfactory.  Some  have 
believed  that  there  was  a  specific  body  in  the  oatmeal  which  might 


374  TREAT  ME  XT 

act  upon  the  liver  or  more  indefinitely  upon  the  general  sugar 
metabolism  and  favor  its  combustion,  but  the  evidence  in  favor 
of  such  a  view  is  unsatisfactory.  Again,  the  effect  of  oatmeal  in 
rendering  the-  kidneys  less  pervious  to  carbohydrate  has  been 
urged  as  a  reason  for  the  apparent  utilization  of  oatmeal,  but  even 
granting  this  to  be  the  case,  it  does  not  seem  probable  that  all  the 
carbohydrate  il2.")0  grams  oatmeal  daily  for  three  days  =750  grams 
oatmeal  =  •">()()  grams  carbohydrate)  given  upon  three  successive 
oatmeal  days  could  be  held  back  in  the  body,  although  it  is  true 
that  Case  No.  '144  (see  page  410)  showed  a  positive  carbohydrate 
balance  while  undergoing  an  oatmeal  cure  under  von  Noorden's 
care.  It  is  noteworthy  that  this  patient  never  became  sugar-free 
after  this  cure  save  for  occasional  days,  despite  vigorous  dieting. 
Furthermore,  an  explanation  of  this  character  would  not  explain 
why  the  oatmeal  treatment  occasionally  fails.  Still  another  explana- 
tion advanced  by  Lipetz  in  190")  is  based  upon  the  possible  rapid 
fermentation  of  the  oatmeal  in  the  intestines,  preventing  its  absorp- 
tion as  sugar,  but  instead  as  decomposition  products  of  the  oatmeal. 
\  arious  writers  have  looked  upon  this  explanation  favorably,  but 
the  general  trend  of  opinion  discountenances  this  theory.  You 
Noorden  has  emphasized  the  absence  of  flatulence  and  has  pointed 
out  the  excellent  digestion  of  the  normal  stools  with  the  oatmeal 
treatment.  Allen  has  critically  examined  the  evidence  of  Rosenfeld, 
Klotz,  and  others  who  have  endeavored  by  a  series  of  experiments  to 
support  the  fermentation  theory,  and  concludes  that  "von  Noorden 
is  correct  in  holding  that  bacterial  processes  are  comparatively 
slight  in  the  upper  part  of  the  small  intestine,  and  that  a  practi- 
cally complete  fermentation  of  the  large  quantity  of  carbohydrate 
administered,  without  symptoms  on  the  part  of  the  patient,  is 
unthinkable." 

The  acidosis  frequently  decreases  or  disappears  following  or 
during  the  oatmeal  cure.  If  such  a  reduction  was  constant  it  could 
be  used  as  an  argument  in  favor  of  the  utilization  of  oatmeal,  but 
unfortunately  it  is  not.  Furthermore,  the  tests  for  acidosis  were 
far  less  accurate  when  the  oatmeal  cure  was  in  vogue  and  con- 
sequently the  data  upon  this  point  are  not  as  complete  as  one 
would  wish.  1  nfortunately,  too,  for  settlement  of  tins  question  the 
treatment  was  complicated  by  the  use  of  fat  in  the  form  of  butter 
which  would  probably  act  exactly  opposite  to  the  oatmeal.  Y\ith 
Case  No.  :!44  the  mild  acidosis  disappeared  upon  the  oatmeal  days 
in  April,  190S.  but  changed  only  slightly  on  a  single  oatmeal  day  in 
September,  1910,  and  August,  1911.  There  was  decrease  in  Cases 
Nos.  L'lli'  and  o71,J  though  this  mav  have  been  due  to  defective 


SPECIAL   DIETETIC   METHODS  375 

elimination  for  the  urine  fell  from  4035  c.e.  before  the  oatmeal  day 
to  3330  c.c.  upon  it  in  the  former  instance  and  from  2520  c.c.  to  1430 
e.c.  in  the  other.  There  was  also  a  striking  decrease  in  the  aeidosis 
with  Case  Xo.  441, l  also  with  Case  Xo.  289. 2  The  ferric  chloride 
reaction  fell  in  intensity  and  upon  a  subsequent  test  August  23  and  24 
the  ammonia  dropped  from  3.2  grams  to  1.7  grams. 

(a)  The  Place  of  Oatmeal  in  Present  Diabetic  Therapy. — It  must 
be  recognized  that  the  employment  of  von  Xoorden's  original 
method  for  the  administration  of  oatmeal  in  severe  diabetes  has 
often  been  followed  by  good  results.  Taking  advantage  of  what 
has  been  learned  since  the  introduction  of  the  oatmeal  treatment, 
the  indications  (?)  for  its  use  in  diabetes  are  as  follows: 

1.  To  cause  a  retention  (increase  the  storage)  of  water,  carbo- 
hydrate, and  protein  in  the  body. 

2.  To  decrease  the  aeidosis. 

3.  To  afford  rest  to  the  digestive  organs,  especially  the  pancreas, 
with  the  hope  thereby  of  improving  the  tolerance  for  carbohydrate. 

4.  To  study  the  problems  involved  under  the  three  preceding 
headings.     For  this  purpose  it  is  an  ideal  food. 

5.  In  a  modified  form  it  may  be  useful  in  replacing  a  fasting  day 
once  a  week. 

The  employment  of  oatmeal  in  the  "oatmeal  cure"  has  stimulated 
its  use  in  smaller  quantities,  and  it  is  undoubtedly  one  of  the  most 
valuable  additions  to  the  strict  diet  of  diabetic  patients.  It  can  be 
given  in  many  different  forms,  it  serves  well  as  a  vehicle  for  butter 
and  cream,  and,  finally,  is  useful  as  gruel  in  the  treatment  of  indi- 
gestion or  diarrhea. 

It  occasionally  happens  that  a  patient  likes  oatmeal  to  such  an 
extent  that  he  is  willing  to  live  almost  exclusively  upon  it  for  weeks 
or  even  months.  I  have  seen  one  such  patient.  Upon  this  diet 
he  did  very  well.  Unfortunately,  such  cases  are  rare. 

In  prescribing  oatmeal  the  dry  weight  should  be  the  measure 
employed,  because  different  brands  vary  enormously  in  bulk  and 
hence  in  content  of  carbohydrate  when  cooked,  because  of  the 
water  employed.  How  wide  these  variations  are  the  following 
table  illustrates: 

TABLE  165. — WEIGHTS  OF  DIFFERENT  VARIETIES  OF  OATMEAL  UNCOOKED 

AND  COOKED. 

UNCOOKED.  COOKKD. 

Quantity,                   Weight,  Xo.  tablespoonfuls,  Weight,  Xo.  tublespoonfuls, 

1  Kill.                         grains.  heaping.  grains.  he-aping. 

H-O  oatmeal       .      .  32  4  353  3-| 

Quakor  oats.       .      .  37  5  325  4 

Scotch  oatmeal.       .  81  5  Sol  10 

American   oatmeal     84  3|  690  6£ 

Irish  oatmeal     .       .  96  5  853  15 

1  Benedict  and  Joslin:   Carnegie  Publication  No.   176,  Case  P,   p.  42. 

2  Ibid.,  No.  136,  Case  J,  pp.  23,  132,  176. 


o/O  TREATMENT 

4.  Other  Carbohydrate  Cures. — (//)  Wheat. — Blum1  believes  wheat 
flour  acts  just  as  efficaciously  as  oatmeal  in  a  carbohydrate  cure, 
and  Csonka2  has  observed  no  difference  between  the  utilization  of 
starch  of  wheat  and  the  starch  of  oatmeal  flour  by  completely 
phlorizinized  dogs.  Blum  demonstrated  that  the  effect  of  the 
oatmeal  or  wheat  was  most  marked  in  the  mild  cases.  He  noted 
that  patients  having  a  positive  carbohydrate  balance  of  70  to  SO 
grains  could  take  200  to  250  grains  of  oatmeal  with  a  similar 
quantity  of  butter  and  occasionally  three  or  four  eggs  or  50  to  75 
grains  of  vegetable  albumin,  and  after  living  upon  the  diet  for  the 
customary  three  days,  and  then  having  a  vegetable  day,  the  last 
trace  of  sugar  would  disappear.  Should  the  diabetes  be  a  little  more 
severe  he  employed  125  to  150  grams  of  oatmeal,  but  the  same 
amount  of  butter.  In  still  severer  forms  of  diabetes  with  acid  intoxi- 
cation only  100  grams  of  oatmeal  were  allowed  for  a  day  or  two,  then 
only  75  grams  for  a  few  days,  and  finally  a  vegetable  day.  In  other 
words,  he  was  fasting  his  patient  to  a  moderate  degree. 

(l>)  Potatoes.— A  potato  diet  was  advocated  years  ago  by  Mosse,3 
and  in  fact  was  the  first  of  the  carbohydrate  cures  recommended 
in  diabetes.  From  what  is  known  now  it  is  easy  to  understand 
why  a  potato  diet  frequently  worked  well.  (1)  The  potato  diet 
was  an  undernutrition  diet  because  no  emphasis  was  laid  upon 
the  simultaneous  use  of  fat;  (2)  there  is  little  protein  in  a  potato; 
(•>)  potatoes  arc1  a  bulky  food,  and  so  satisfy  the  patient's  appetite. 
The  claim  that  considerable  quantities  of  alkali  are  thus  intro- 
duced into  the  system  does  not  rest  upon  a  firm  foundation.  I  have 
had  little  experience  with  potato,  but  in  2  cases  (Xos.  7(15  and  806) 
iu  which  it  was  employed,  respiratory  quotients  gave  no  evidence 
that  it  \vas  assimilated.  (Table  S2.) 

In  small  quantities  potato,  like  oatmeal,  is  most  valuable.  It 
carries  butter  well,  contains  only  about  one-third  the  quantity 
of  carbohydrate  in  bread,  and  is  easily  measured.  A  potato  the 
si/e  of  an  egg  weighs  about  00  grams,  whether  cooked  or  uncooked, 
and  contains  12  grams  carbohydrate.  \\ith  a  good  many  mild 
cases  of  diabetes  it  is  advantageous  to  exclude  bread  entirely  from 
the  diet  and  to  substitute'  potato,  of  which  the  quantity  need  be 
only  slightly  restricted.  One  hundred  grams  of  carbohydrate  in 
the  form  of  100  grams  bread  are  quickly  eaten,  but  it  is  not  so  easy 
to  take  the  same  100  grains  carbohydrate'  in  500  grains  of  potato. 

Little  potatoes,  carefully  cleaned,  when  baked  are  often  eaten 
with  the  skins  by  patients  with  much  relish,  and  with  relief  to  their 
constipation  as  well. 

1  Blum  :.Soinuino  Modioulo,  1!*13,  xxxiii,  p.  .'-il.'i. 

s  Csoiika:  .lour.  Am.  Mod.  Assn.,   1910,  Ixvii,  p.  1114. 

3  Mo.-or:   ROMIO  de  mod.,  l'JU_',  xxii.  up.  1U7,  279,  371,  020.     Cited  by  Xaunyn. 


SPECIAL  DIETETIC  METHODS  377 

(c)  Bananas. — Bananas  have  been  advocated  by  von  Xooraen 
as  a  substitute  for  oatmeal.  Like  potatoes  they  contain  about 
20  per  cent,  carbohydrate.  Most  of  the  carbohydrate  is  in  the 
form  of  starch,  but  when  the  banana  thoroughly  softens  and  ripens 
this  changes  to  sugar.  Bananas  are  usually  eaten  in  the  starch 
stage.  The  carbohydrate  in  one  banana  is  about  20  grams. 

The  average  weight  of  12  whole  bananas  was  141  grams  and 
the  weights  varied  between  119  and  167  grams.  When  peeled  these 
same  bananas  weighed  on  the  average  87  grams,  the  minimum 
weight  being  73  grams  and  the  maximum  weight  101  grams.  It 
is  therefore  approximately  correct  to  consider  that  a  whole  banana 
weighs  about  140  grams  with  the  skin  on  and  not  far  from  90 
grams  peeled.  (See  Table  127,  p.  264.) 

For  the  same  reasons  that  I  employ  potatoes,  I  prefer  to  give 
bananas  rather  than  bread  to  the  patients.  It  is  so  much  easier  to 
eat  too  much  bread  than  banana. 

((/)  The  Milk  Cure. — Milk  was  advocated  as  an  exclusive  diet 
for  diabetic  patients  by  Donkin1  some  years  ago,  and  recently 
attention  has  been  again  called  to  it  by  Williamson.2  It  has  not 
come  into  favor.  Unfortunately,  it  is  so  simple  to  prescribe  a  milk 
diet  that  this  is  often  done,  and  it  is  not  uncommon  to  see  patients 
taking  large  quantities  of  milk  with  distinct  harm  to  themselves. 
It  was  not  intended  by  the  original  promoters  of  the  milk  cure  that 
other  foods  should  be  simultaneously  eaten,  but,  as  so  often  happens, 
the  original  directions  have  been  overlooked.  Still  more  harmful 
than  the  indiscriminate  use  of  milk  has  been  the  advice  to  drink 
buttermilk. 

Buttermilk  contains  all  the  carbohydrate  which  is  in  ordinary 
milk,  but  the  fat  which  contains  so  much  nutriment  for  the  diabetic 
has  been  removed.  Buttermilk  might  be  employed  temporarily, 
but  as  an  addition  to  the  strict  diabetic  diet  would  be  harmful. 

Case  Xo.  17  is  the  only  one  in  my  series  which  has  shown  an 
apparent  tolerance  for  milk:  Male,  teacher,  onset  of  diabetes  at 
the  age  of  fifty-five;  came  under  my  observation  in  August,  1900, 
at  the  age  of  sixty,  having  lost  27  pounds,  1(5  per  cent,  from  his 
highest  weight.  Upon  a  diet  of  3000  c.c.  milk,  containing  150 
grams  carbohydrate,  which  he  had  employed  with  only  trifling 
additions  for  a  period  of  six  weeks,  the  sugar  in  the  urine  was  only 
13  grams.  During  this  period  weight  fell  1  kilo.  I  endeavored  to 
make  him  sugar-free,  and  lowered  the  carbohydrates  in  the  diet 
to  25  grams,  but  the  sugar  in  the  urine  fell  only  to  9  grams.  I  well 
remember  having  greatly  increased  the  protein  and  fat  in  the  diet 
when  the  milk  was  omitted.  Undoubtedly  the  secret  of  the  favor- 

1  Donkin:  British  Mcd.  Jour.,  1S74,  i,  p.  838. 

2  Williamson:  British  Med.  Jour.,   1915,  i,   p.  456. 


378  TREAT  MK  XT 

able  course  of  the  patient  upon  the  milk  diet  was  the  comparatively 
small  number  of  calories  which  he  obtained  and,  conversely,  the 
harmful  effect  of  the  rigid  protein-fat  diet  was  due  to  the  large 
number  of  calories  it  contained  as  well  as  to  the  acidosis  which 
my  records  of  sixteen  years  ago  show  it  brought  on.  I  low  plain  the 
explanation  of  this  case  is  today,  but  for  a  long  time  it  was  a  puzzle. 
(c)  Levulose. — Since  the  publication  of  our  second  monograph  in 
I!)!.?,  F.  G.  Benedict  and  I  have  continued  our  studies  upon  the 
respiratory  metabolism  of  diabetic  patients.  Save  for  references 
to  this  in  my  Harvey  Lecture,1  the  material  has  not  been  published. 
We  have  felt  it  was  better  to  accumulate  data  and  correlate  the 
whole  in  a  single  report.  The  utilization  of  carbohydrates  has  been 
our  chief  problem,  but  we  have  also  included  the  study  of  other 
subjects  if  they  appeared  of  sufficient  interest  to  warrant  divergence 
from  the  main  theme.  In  the  interim  of  these  five  years,  much 
helpful  work  has  come  from  other  laboratories,  and  the  measurement 
of  body  surface,  the  studies  upon  fasting  and  other  individuals  have 
introduced  new  conceptions  as  to  the  methods  of  determining  the 
basal  metabolism.  It  was  not  my  intention,  and  indeed  I  did  not 
think  it  wise,  in  this  book  or  at  this  time  to  refer  to  the  work  which 
Benedict  and  I  and  our  associates  have  done,  but  the  interest  which 
the  more  recent  experiments  with  levulose  must  awaken  in  thinking 
patients  and  doctors  led  me  to  ask  Dr.  Benedict  for  the  privilege 
of  reporting  4  severe  cases  of  diabetes  in  which  levulose  has 
appeared  to  do  good.  To  my  request  Dr.  Benedict  instantly  and 
whole-heartedly  assented.  The  significance  of  these  experiments 
lies  in  the  fact  that  whereas  these  patients  with  whom  the  tests 
have  been  tried  formerly  fasted  one  day  a  week,  we  substituted 
for  the  weekly  fasting  day  a  levulose  or  levulose  and  oil  day,  thereby 
securing  for  them  additional  calories;  that  in  each  case  the  total 
metabolism  and  in  most  cases  the  respiratory  quotient  rose;  that 
ni)on  these  days  the  urine  remained  sugar-free,  or  if  any  sugar 
appeared  it  promptly  disappeared  even  if  the  full  diet  of  the  day 
preceding  the  levulose  day  was  resumed  the  following  morning; 
that  in  some  instances  the  blood  sugar  was  lower  the  day  after 
the  levulose  than  it  was  before  the  levulose  was  taken  and  seldom 
at  all  higher;  that  following  the  treatment  or  in  spite  of  it,  - 
cases  of  diabetic  inanition,  from  being  unable  to  stand,  were  in  the 
course  of  several  weeks  able  to  get  out  of  bed  and  walk,  and  that  in 
each  of  these  cases  the  eU'ect  upon  the  carbohydrate  tolerance  was 
favorable.  In  these  cases  acidosis,  though  formerly  existing  in  i>, 
was  absent  when  the  levulose  was  given.  How  le\  ulose  acts  in  the 
presence  of  acidosis  will  be  later  discussed,  as  will  also  the  eil'ect 

1  Jo^lin:   Luc.  oil.,  p.  HO, 


SPECIAL  DIETETIC  METHODS  379 

of  the  substitution  or  addition  of  protein.  In  nil,  Benedict  and  I 
have  made  44  experiments  with  leviilose.  These  must  be  analyzed 
as  a  whole  before  conclusions  can  be  drawn,  but  to  the  keen  eyes 
of  those  working  upon  the  respiratory  metabolism,  other  hints  of 
peculiarities  in  the  metabolism  of  these  patients  will  be  disclosed 
than  those  already  mentioned,  should  a  careful  examination  of  the 
data  in  the  charts  be  made. 

The  selection  of  leviilose  for  these  tests  was  partly  by  accident. 
Another  form  of  carbohydrate  may  act  as  well.  I  have  resisted  the 
advice  and  temptation  to  try  such  until  recently.  I  have  seen  so 
many  methods  of  treatment  fail  in  diabetes  that  if  anything  promises 
well,  I  prefer  to  abide  by  it  until  its  utility  has  been  proved  or 
disproved.  In  our  early  cases  leviilose  was  given  alone  one  day  a 
week,  and  examinations  of  the  respiratory  metabolism  as  well  as  of 
the  blood  and  urine  were  made  both  before  and  after  its  adminis- 
tration. In  later  cases  the  same  plan  was  followed,  but  upon  the 
theory  that  if  carbohydrates  are  burned  fat  would  be  burned,  too, 
olive  oil  was  also  given.  In  no  instance  has  the  patient  shown  an 
acidosis  upon  such  a  day,  or  an  increase  of  sugar  in  the  urine  above 
that  of  a  levulose  day  pure  and  simple. 

By  no  means  do  I  recommend  the  general  use  of  levulose  in  all 
cases. 

It  is  quite  possible  that  these  cases  have  done  better  than  would 
others.  To  show  how  conservative  I  am  in  regard  to  the  whole 
question,  I  am  selecting  a  new  case  for  observation  only  every  two 
or  three  weeks,  and  each  case  is  being  investigated  by  Dr.  Benedict 
and  me  with  all  the  facilities  in  our  control.  Indeed,  one  of  the  chief 
reasons  for  publishing  these  cases  at  this  time  is  to  evoke  constructive 
criticism  which  will  help  in  the  laborious  analysis  of  the  past  five 
years  of  work,  and  in  future  experiments.  From  the  therapeutic 
stand-point  I  wish  others  would  repeat  or  continue  in  a  better  way 
our  experiments.  If  they  do  not,  it  will  take  too  long  to  find  out  all 
the  faults  or  advantages  of  this  plan  of  treatment.  Furthermore,  I 
dislike  the  thought  of  having  my  patients  bear  the  brunt  of  all  the 
tests.  These  experiments  remind  me  of  my  Italian  diabetic  years 
ago  at  the  Boston  City  Hospital,  who  went  through  his  typhoid 
fever  successfully  on  a  diet  of  oatmeal  and  olive  oil. 

The  story  of  the  4  cases  follows: 

Case  Xo.  1190,  having  had  diabetes  for  seven  years,  came  to  me 
in  December,  1910,  minus  fifty-three  pounds  of  his  former  best 
weight,  with  G  grams  of  ammonia  and  an  alveolar  air  of  22  mm. 
mercury.  For  his  treatment  at  this  early  stage  my  assistant,  Dr. 
Ilornor,  deserves  all  the  credit.  Proof  that  alkalis  are  unnecessary 
unless  the  ammonia  exceeds  6  grains,  and  the  alveolar  air  is  below 
IS  is  evident,  because  the  soda  he  had  been  receiving  was  omitted 


w 

M 
t- 


U 


>>  g    'juoponb  Ajo; 


o 


-uiui  jod  -j-a 


Ji 

£H     C 


'BUISBJjJ 


—1         IN         — 


-^C^Tf<OClOO'-i-tf~        OOC5      •  "-I      •        OtCi 

(N  C^l  C-J  —  I  C-l  -M  -M  OJ  ri         -M  -M      •  •  CO      •        CC  C-l 


•i!nisi:[([ 
I  '>l°'IA\ 


•4110,)  jod  'ji:3ns 


•souopiQ 


-r      7i .-  c~.      -r      -t 

71  71  -H  O  rH  ,-H 

o     coo     o     d 


•+T i 7 i 77 i = i i =    i 0+++++++ 


- 

co  X'  cr.  o; 

o  o  o  o 


•]oqoo[\-  i    |      o     cooo    -o 


oo7iiooo-7<T}<o     -roocooooo 


•suia  'iji:x 


•|U.I,J    J.lll    'UMIIM 


+     ,  ++ 


Ci       X       1^  'f.  f-  X 


cc=  a 

o       c.  c.  o  . 


SPECIAL  DIETETIC  METHODS 


381 


Respi 
meta 


•uiui  aad  'O'O  SQ 


•uira  J9d  -o-o  ZQQ 


•3jj-imn'2 


•sop 


-pooiq 


'  pooiq 


co  L-  o  o  c:  s 


'SUl3    'UOSOJ^I 


IOB  OI^OOBIQ 


+     +  •  • 


•sojiif  '^ 


OXOClt^COCOOX 


-7  °  £  c  !•=  = 

-£>st^    £>s-2  ^BS"?-^ 

ai  u£  'a           a  S><£  C  a)^1-       c 

P5.-K      B          C5^<a  C53-<      H 


382  TltEATMEXT 

and  following  tliis  the  aciclosis  dropped,  and  5n  seven  days  dis- 
appeared, not  to  return  while  at  the  hospital.  His  strength  failed, 
and  finally  he  could  hardly  move  in  bed,  and  he  said  lie  was  too 
weak  to  ring  the  electric  bell,  though  later  lie  often  complained  that 
the  nurses  forced  him  to  regain  strength  in  this  manner.  The 
lowest  recorded  weight  was  eighty-six  and  a  half  pounds,  and  he 
certainly  lost  ten  pounds  more.  On  repeated  occasions,  without 
acidosis  and  when  at  his  lowest  ebb  he  showed  a  remarkable  excretion 
of  nitrogen  amounting  to  as  much  as  4;>.l  grams  in  one  period  of 
twenty-four  hours.  It  is  true  that  he  had  a  few  vagaries,  such  as 
a  passion  for  saccharin  tablets  (21,  each  of  one-half-grain  strength 
per  day),  bouillon  cubes,  cocoa  butter,  salt,  celery  salt,  various 
peppers  and  similar  delicacies  furnished  by  thoughtful  angel  visitors, 
but  he  assures  me  that  nothing  was  taken  to  account  for  so  high 
a  nitrogen,  and  he  fully  realizes  the  importance  of  the  statement. 
1  believe  the  nitrogens  trustworthy. 

It  will  be  seen  that  all  the  levulose  was  not  tolerated,  but  the 
quantity  of  sugar  appearing  in  the  urine  was  comparatively  small. 
The  chart  shows  the  progress  of  this  patient;  he  is  gradually  gaining 
tolerance,  and  I  have  transferred  his  case  to  Dr.  Brigham  and  Miss 
Lundholm. 

In  the  following  cases  levulose  was  given  on  one  day  each  week, 
replacing  the  fast  day,  for  several  weeks.  The  quantity  was  limited 
to  one  gram  or  one  gram  and  a  half  per  kilogram  body  weight. 

Case  Xo.  032,  Table  107.  A  young  officer,  aged  thirty-five  years, 
with  diabetes  of  one  and  a  half  years'  duration  came  to  me  first  in 
1913.  At  the  hospital  diacetic  acid  showed  repeatedly,  and  the  am- 
monia was  1 .7  grams,  but  the  tolerance  for  carbohydrate  lay  between 
1 5  and  30  grams.  Nevertheless  he  was  discharged  with  0.5  per  cent, 
of  sugar  in  the  urine,  and  diacetic  acid  was  present,  with  a  diet  of  30 
grams  carbohydrate  and  a  limited  quantity  of  protein,  though  with 
an  unlimited  amount  of  fat.  He  returned  in  February,  1910,  and 
it  required  twelve  days  to  rid  the  urine  of  sugar  and  twenty-one 
days  to  rid  it  of  acid.  Table  107  contains  the  result  of  the  adminis- 
tration of  levulose,  levulose  and  oil,  and  protein  and  dextrose  on  one 
day  weekly  instead  of  a  fast,  day.  Kxcrcise  was  utilized  to  the  limit, 
and,  as  to  be  expected  of  an  army  man  with  a  Victoria  ( Yoss, 
obedience  was  implicit,  cooperation  ever  present,  and  system  exact. 
I  have  permission  to  publish  this  letter  received  eleven  months  after 
leaving  the  hospital. 

M.vucu  8,  1!)17. 

"1  have  really  been  wonderfully  well,  feel  splendid  and  everyone 
remarks  ho\v  well  I  am  looking.  Tests  have  shown  a,  slight 
trace  of  sugar  on  three  mornings  since  October  S,  last;  all  other 
times  absolutely  sugar-free.  Mv  weight  doesn't  change  at  all 


SPECIAL   DIETETIC   METHODS 


383 


— if  anything  I  have  gotten  very  slightly  lighter.  I  weigh  -from 
1242  to  12o2  pounds.  I  still  stick  absolutely  rigidly  to  my  routine, 
but  I  have  gotten  up  to  30  grams  carbohydrate  per  diem;  that  is,  on 
the  last  five  days  of  the  week  I  take  30 — rest  of  diet  the  same.  The 
last  three  weeks  I  have  been  taking  15  grams  oatmeal  for  breakfast 
on  Monday,  Tuesday,  Thursday,  Friday  and  Saturday  mornings, 

TABLE  168. — CASE  No.  1213,  P.  384.    LEVULOSE,  CHANGE  JUICE,  ADDITION  OF  PROTEIN,  CLIVE  OIL. 


Date, 

1917. 

_o 
M 

_M 

'o 

& 

31  'l 
30.7 
30  .  6 
30.5 
30.3 
34.2 
31.4 
30.8 
31.3 

Urine. 

Diet  in 
grams. 

Blooc                                   Respiratory 
1MOOC1-                                  metabolism. 

oJ 

3 
[3 

-r 

a 
-, 

o 
o 
- 

'~ 

5 

£3 
c 
a 

c 
h 

Z 

5 
C 
SL 
-j. 

3 
0 
0 
0 
0 
tr. 
2 
2 
2 
0 
0 

_c 

- 
-- 

> 

C 

1 

C 

0 

l 
( 
0 
0 
0 

( 

.':' 
( 
0 
0 

c 
'£ 

c 

r. 

PK 

c 
,c 

L 

*L* 

_0 

O 

u 

F* 

a 

c 
- 

bl 

5. 

Fat. 

o 

_S 

3 

>, 

0 

'E 
0  So 

Total  fatty 
acids. 

L-t>-       ^S"      | 

1 

_o 
"3 

1 

d 
C 

a 

E 

c 

~:. 

n 
8 

O 

o 
c 

1 

g 

_rj 

^                    t- 

c              •      & 
c      °              o      & 

c,    "3     5     5.      - 

%   ~   J    fe   6 
o   ^   S  o  o 

Before  experiment 
Before  levulose 
Levulose  given 
After  levulose  . 

Before  experiment 
Before  levulose 
Levulose  given 
After  levulose,  oil  30 

Before  levulose 
Levulose  given 
After  levulose,  oil  60 

Before  experiment 
Before  levulose 
Levulose  given 
After  levulose,  fish 
240            ... 

Before  experiment 
Before  levulose 
Levulose  given,  oil  60 
After  levulose  . 

Before  experiment 
Before  levulose 
Levulose  given,  oil 
60        .... 
After  levulose  . 

Jan.      5 
6 
7 
8 
9 
10 
11 
Feb.     3 
4 
5 
0 

8 
13 

14 

15 
1C 

20 

21 

22 

27 

28 
M-ir      1 

2700 
1500 
1950 
2500 
2800 
2350 
2000 
2100 
1XIK, 
1900 
1400 

0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 

13.2 

T'.G 

0 
12 
30 
12 
50 
5s 
5s 
39 
:>7 
16 
37 

0 
0 

1-' 

_>L> 
II 

n 

50 
(12 
5s 
24 
41 

0 

( 

0 

( 

0 

0 
0 
14 
14 
LI 
14 

0 
48 
228 
366 
560 
(119 
682 
824 
768 
308 
615 

.26 
.20 

.21 

0.47 

O.C5 

.21 

.31 

.  32 

.30  .27  .36  .14 

7s 

93 

31  il 

31  '.  3 

2454 

2450 
2500 

0 

2    GO 

0 

0 

0 

240 

101 

120 

104 
134 

99 
110 

93 

11- 

0.81 

0.8 
O.M) 

0.87 
0.97 

0.91 
0  91 

0 
0 

8.5 

0 
0 

2 

5 

29 

38 

37 
76 

11 
1-1 

555 
946 

.  ~O 

S4 

1295 

0 

.  .      1 

60 

0  .  . 
30 

5 

545 

113 

31.7 
31.0 
31.8 

31  '3 

31  '  8 
33.3 

1400  0 
2800  0 
1700  0 

6.6 

1 
0 

0 

5  3959  14    S05 
4  '23  35  14    421 
649:83141061 

8fi 

1535  0 

1700  0 
1600  0 

i'.b 

1 

tr. 
0 

(30 

6 
2 

0.  . 

.  .  60 
4063 
4679 

5 

11 
1  1 

815 

813  .']-> 
1001 
.  .     .  2S- 

107 

84 

.  .     1885 

0 

7 

»6 

IK 

0 

5 

347 

0  OS-  1    17    58 

3'1 

:\:,   47    17   CM    iq'in." 

2 

3 
4 

5 

(•> 

8 
14 

32.71900  0 
32  .  5  2800  0 
31.82300  0 
32.41,800  0 
32.62100  0 

2 

3 
2 

tr. 

tr. 

640 
648 
045 
037 
037 

74  14    948 
81  141043 
7514    953 
7614,  930 
7614    930 

.2P 

88 

105 

118 

111 
132 

0.84 
1.00 

0  .  84 
1.91 

1210 

0 

2 

60 

6 

60 

5 

815 

.  lie 

W.7  1700 

0 

0 

5 

_'7 

61 

1  1 

775 

.23 

.  '  .  93 

31.7 

11(10 

(] 

tr. 

60 

OiiO    5 

815  .  . 

I  .  0    1  .  39  .  24 

.43 

,4s  .32  .52  .OS  .21 
.    119 

0 . 91 1 . 18  .  34  . 42  .  39  . 48  .51  . 62 . 28 


384 


TREATMENT 


Wednesday  all  carbohydrate  in  .")  per  cent,  vegetables  and  cream, 
Sunday  (fast  day)  all  carbohydrate  in  5  per  cent,  vegetables." 

Case  No.  11213.  This  little  patient  of  seventeen  years,  so  weak 
that  the  students  carried  her  up  to  the  amphitheatre  in  the  Peter 
Bent  Brigham  Hospital  that  I  might  show  them  a  case  of  inanition, 
and  I  carried  her  upstairs  on  her  return  to  the  Deaconess  Hospital, 
first  came  to  me  on  January  5,  1(,)17,  weighing  sixty-eight  and  a  half 
pounds,  with  the  story  of  having  lost  fifty  pounds  in  the  preceding 
year,  the  onset  of  diabetes  being  placed  in  May,  1010.  She  showed 
3  grams  sugar  on  a  fasting  day,  but  no  acid,  and  said  she  could  not 
tolerate  protein.  I  accepted  the  challenge,  gave  protein,  and 
found  she  had  50  grams  tolerance  therefor,  in  the  presence  of  40 

TABLE  160. — CASE  Xo.  123.'},  P.  3S5.    LEVULOSX,  OKA.\<;E  JUICE,  ADDITION'  OF  OIL  ou  BUTTER. 


Before  experimf 
Before  levulose 
Levulose  tnven 
After  levulose 


Before  exporin 

Before  levulos. 
Levulose  tiivei 
After  levulose, 


After  levulose 
I'jrul  of  experi 


Before  experi 
Before  levulo: 
<  (ranges  (jivei 
After  leviilo.-e 
Next  inornin 


SPECIAL   DIETETIC   METHODS  3X5 

grams  of  fat.  But  she  lingered  along,  as  her  chart  shows,  and  I 
decided  to  give  her  levulose  on  her  fasting  day  and  with  what  result 
the  record  makes  plain.  Apart  from  the  documentary  evidence  this 
afforded,  I  may  add  that  in  April  she  walked  between  one  and  two 
miles  in  a  day.  Each  day  massage  was  given  by  Mr.  Sundelius  or 
the  patient's  mother.  Her  weight  is  now  71 1  pounds  and  her  diet 
carbohydrate  10  grams,  protein  36  grams,  fat  83  grams. 

Case  Xo.  1233,  aged  twenty-seven  years,  had  been  fasted  and  fed 
alternately  since  his  diabetes  began  fourteen  months  ago.  He 
differed  from  the  other  3  cases  in  that  he  showed  edema,  and  the 
blood-pressure  was  110  systolic  and  80  diastolic.  The  urine  showed 
only  the  slightest  possible  trace  of  albumin,  and  no  casts;  the 
phenolphthalein  excretion  varied  between  zero  and  24  per  cent., 
and  the  non-protein  nitrogen  was  successively  110,  95  and  120  mg. 
per  100  c.c.  blood,  but  eight  days  later  28  milligrams. 

He,  too,  tolerated  levulose  and  levulose  and  oil,  later  oranges 
and  oil,  oranges  and  butter,  to  a  surprising  degree  each  scheduled 
fast  day,  and  his  edema  finally  disappeared.  He  was  discharged 
upon  the  following  diet:  carbohydrate  30'  grams,  protein  70  grams 
and  fat  112  grams,  with  the  advice  to  take  carbohydrate  20  grams 
and  oil  20  grams  three  times  in  the  day  on  one  day  each  week  instead 
of  a  fast  day.  (Table  1G9.) 

5.  Rectal  Injections  of  Sugar. — The  experiments  of  Arnheim  in 
1904  showed  that  glycosuria  in  diabetic  patients  was  not  increased 
after  enemata  of  solutions  of  sugar.  Simultaneously,  acetonuria 
diminished,  and  this  appeared  to  be  good  proof  that  the  sugar  was 
absorbed  and  oxidized.  This  favorable  action  was  attributed  to 
the  slow  absorption  of  the  rectal  injection.  Since  this  time  others 
have  studied  the  problem,  notably  Bingel,  Reach,  Ballint,  Liithje, 
Jahnson-Blohm  and  Petitti.1 

The  subject  is,  however,  by  no  means  settled.  The  whole 
matter  should  be  reinvestigated,  for  the  conditions  are  now  much 
more  favorable  for  its  solution.  In  the  first  place,  it  is  questionable 
whether  in  former  experiments  one  sufficiently  considered  the 
effect  of  fasting,  and  secondly,  the  possibility  of  carbohydrate 
storage  following  fasting.  Finally,  today  the  respiratory  exchange 
is  far  more  generally  employed,  and  this  is  really  the  ultimate  test. 
Experiments  dealing  with  rectal  alimentation  of  normal  individuals 
will  throw  much  new  light  upon  the  question,  and  these  have  been 
in  progress  for  some  time  under  the  direction  of  Dr.  Carpenter  of 
the  Nutrition  Laboratory.  Dr.  Carpenter  has  been  kind  enough  to 
give  me  the  following  preliminary  summary  of  some  of  his  tests. 
From  these  it  is  evident  that  absorption  of  the  sugar  is  between  31 
and  72  per  cent.  (Table  170.) 

1  SOP  Allen,  Loc.  cit. 
25 


3Mi  TREATMENT 

TABLE  170. — PRELIMINARY  SUMMARY  OF  RESULTS  OF  INJECTION  BY 
KECTUM  OF  LEVULOSE  AND  DEXTROSE  SOLUTION.' 

(T.  M.  Carpenter,  Ph.D.) 


Amount 
given, 

gins. 

Amount  of 
liquid, 

Time 
retained. 
llrs.     Min. 

Amount  in 

washout, 
Kins. 

Amount 
absorbed, 
Kins. 

Remarks. 

E 

XPEli 

I  MEN 

T.S  WITH  C 

OMMERCIA 

L    LEVULOSE. 

50.0 

500             3 

30 

18.0 

32  .  0 

One  washout  at  end. 

50.0 

500            2 

38 

25  .4            24  .  6 

Defecation  and  washout. 

50.0 

1000             3 

20 

16.7 

33  .  3 

Defecation  and  washout. 

50.0 

1000             2 

13 

21.6 

28  .  4 

Defecation  and  washout. 

25.0 

500             3 

12 

7.8 

17.2 

Two  washouts  at  end. 

25.0 

500 

2 

48 

3.8 

21  .2 

Two  washouts  at  end. 

25.0 

500 

3 

12 

1.8 

23  .  2 

One  washout. 

25.0             500 

3 

00            2.7 

22  .  3 

Two  washouts. 

37  .5 

750 

2 

37 

0.7(?) 

One  washout. 

V.  YPT.'DTM  I.' 

NTS  W 

TTTr     K 

MILBAUM 

<1T      rnrx 

/rcKKR  (GEREINIGT). 

00.0           1000 

5         00 

24.0            36.0 

Two    washouts   at  end;   much 

cramps. 

30.0             500 

3 

49 

11.3 

1S.7 

Two    washouts;   subject   com- 

fortable. 

30.0 

500            4         46 

S.O 

22.0 

Two     washouts;     no     cramps; 

so7iie  peristalsis. 

30.0             500 

3 

47            5  .  6 

24.4 

Two  washouts;  comfortable. 

30.0 

500 

3          33           11.1 

18.9 

Hard    to   retain   solution;   one 

washout. 

30.0             500 

6           11.0             19.0 

Very  comfortable;  two  wash- 

outs. 

30.0             500             4            0             9.0             21.0 

Reported  gas  pains;  two  wash- 

outs. 

30.0             500' 

4            0             5.2             24.  8 

Comfortable;   two  washouts. 

Liithje2  repeatedly  witnessed  the  disappearance  of  aeidosis  during 
the  treatment  of  patients  with  enemata  of  sugar.  As  evidence  of 
the  absorption  of  sugar,  lie  observed  an  increase  of  the  percentage 
of  sugar  in  the  blood,  and  controlled  the  observation  by  noting 
no  such  increase  following  the  administration  of  salt  solution. 
The  slow  absorption  of  the  sugar  did  not  account  for  its  better 
utilization  when  given  by  the  rectum,  because  when  sugar  was 
introduced  into  the  body  at  the  same  rate  by  being  slowly  sipped, 
the  difference  in  favor  of  rectal  alimentation  persisted.  Liithje  found 
that  with  good  technic  patients  may  absorb  one  or  two  liters  of  solu- 
tions of  sugar  containing  5.4  per  cent.,  and  thus  may  get  ">()  to  100 
grams  a  day.  Ten  patients  were  treated  by  him  by  this  method. 

Hergmark  also  showed  that  after  enemata  of  dextrose  there  was 
an  increase  in  the  carbon  dioxide  production,  and  that  the  experi- 
mental aeidosis  diminished  as  well.  Recently,  Jalinson-Blohm 
found  that  with  healthy  subjects  the  instantaneous  as  well  as  the 

1  Nearly  all  of  the  respiration  experiments  showed  a  more  or  less  positive  rise  in 
(lie  respiratory  <|iioticnt  after  the  injection  of  the  sutrar  solutions  (February  2,  1917). 
•  Liithje,;    Therapic  tier  Gcjrfiiwart,  1U13,  liv,  p.  193. 


TREATMENT  OF  ACID  INTOXICATION  387 

repeated  doses  by  mouth  gave  inside  of  the  first  three  and  one- 
fourth  hours  a  strong  increase  in  the  glycemia,  which  rapidly  sank 
in  several  cases  so  far  that  hypoglycemia  took  place.  Dextrose 
injected  by  rectum  gave  blood-sugar  values  which  lay  very  near 
to  those  at  the  beginning,  and  inside  the  limits  of  error  of  the 
method.  The  experiments  with  the  diabetic  subjects  showed  a 
strong  rise  of  the  blood-sugar  curve  with  ingestion  of  dextrose  by 
mouth.  As  with  the  normal  subjects,  the  rectal  experiments  gave 
no  increase  in  the  percentage  of  the  blood  sugar.  An  increase  in 
the  urinary  sugar  did  not  occur  either  with  healthy  or  diabetic 
subjects  after  the  rectal  feeding.  This  work  well  shows  the  unsettled 
state  in  which  the  question  now  rests,  but  Benedict's  and  my  experi- 
ments with  levulose  and  other  carbohydrates  will  help  in  its  solution, 
as  will  also  the  simplification  of  treatment  which  fasting  has  created 
and  the  more  accurate  knowledge  of  diabetes  which  refined  analyses 
of  blood,  urine  and  the  respiratory  metabolism  afford. 


I.     THE  TREATMENT  OF  ACID  INTOXICATION  AND 
DIABETIC  COMA. 

In  the  plan  of  treatment  of  diabetes  outlined  thus  far,  emphasis 
has  constantly  been  placed  upon  the  prevention  of  acidosis  and 
coma.  To  this  end  it  has  been  recommended  to  omit  fat  from  the 
diet  as  a  preliminary  to  fasting,  then  fast  and  resume  the  diet,  by 
beginning  with  carbohydrate,  following  with  protein  and  ending 
with  fat. 

These  procedures  often  suffice  both  to  prevent  acidosis  and  to 
abolish  it  if  present;  but  when  the  acidosis  threatens  to  be  severe, 
the  following  rules,  now  in  force  for  my  cases  at  the  New  England 
Deaconess  and  Corey  Hill  Hospitals,  are  suggested.  They  will 
usually  avail  even  at  a  stage  when  the  patient  is  conscious,  but  ex- 
hibits the  labored  breathing  of  diabetic  coma.  They  have  not  been 
successful  when  the  patient  has  been  unconscious,  or  the  CO2  in  the 
alveolar  air  has  been  below  15  mm.  mercury,  though  I  am  confident 
that  some  cases  even  of  this  type  will  eventually  be  saved  if  the 
orders  are  faithfully  followed.  These  rules  are: 

1.  Nursing. — Provide  a  special  nurse  for  the  patient  for  both 
day  and  night,  and  preferably  one  trained  in  diabetic  work. 

2.  Bed. — Keep   the   patient    in   bed   and   warm.     Avoid  loss  of 
calories  through  exertion  or  exposure;  if  restless,  protect  from  be- 
coming chilled  by  flannel  night-clothes.     Every  effort  should  be 
made  to  allay  nervousness  and  discomfort. 

3.  Care  of  the  Bowels. — Move  the  bowels  by  one  or  more  enemata. 
Cathartics  should  usually  be  avoided  for  fear  of  causing  diarrhea. 


3SS  TREATMENT 

4.  Administration  of  Liquids. — Give  1()(K)  c.c.  of  liquids  within  each 
six  hours.  The  liquids  are  to  be  given  slowly,  hot,  as  coffee,  tea,  thin 
broths,  \vater;  if  the  prospect  is  dubious  of  giving  so  much  liquid  by 
mouth,  salt  solution  or  tap  water  is  to  be  given  by  rectum;  if  this 
resource  fails,  the  nurse  should  call  the  doctor  to  give  intravenously 
the  balance  of  the  liter,  which  remains  not  given  for  the  period. 
(It  will  seldom  be  found  necessary  to  give  more  than  1000  c.c. 
liquids,  thanks  to  the  avoidance  of  alkalis.)  In  order  to  secure  the 
introduction  of  sufficient  liquid  in  the  first  six  hours,  the  cleansing 
enema  at  the  beginning  of  treatment  should  be  followed  after  half 
an  hour  by  an  enema  of  500  c.c.  salt  solution  in  all  cases  as  a  matter 
of  precaution. 

f>.  Diet.  ~  If  the  patient  has  been  accustomed  to  the  fasting 
method  of  treatment,  begin  or  continue  the  fast,  but  if  he  has  been 
upon  a  full  diet,  give  a  gram  of  carbohydrate  per  kilogram  body 
weight  during  the  twenty-four  hours  in  the  form  of  orange  juice 
or  gruel  (oatmeal)  made  with  water;  whichever  course  is  adopted, 
it  is  to  be  followed  until  danger  is  over. 

(i.  The  Heart. — Sustain  the  circulation  with  the  help  of  digitalis. 
( 'affein  may  be  given  subcutaneously  or  as  black  coffee  by  the  rectum. 

7.  Alkalis. — Avoid  alkalis.  If  such  have  been  previously  given, 
omit  at  the  rate  of  '.>()  grains  a  day. 

The  results  obtained  with  these  measures  will  be  briefly  sum- 

i 


1 .  Table  171  shows  that  there  has  been  a  steady  fall  in  the  number 
of  patients  who  have  developed  acidosis  after  entrance  to  the 
hospitals  and  is  compiled  from  tables  1-47-140. 

TABLE   171. — ILLUSTRATIVE  OF  THE  PKEVEXTIOX  OF  ACIDOSIS  IN  TMHEE 

SUCCESSIVE  (lnori's  OF  THIRTY   PATIENTS   KACH   ADMITTED  TO  THE 

NEW  ENGLAND  DEACONESS  AND  COKEY  HILL  HOSPITALS. 


Group. 

1. 
April.  HI1.1,  to  March,  1010     ...      7  If) 

.       .      4  (i 

•2  112 


~1.  The  following  cases  of  severe  acidosis  have  been  treated  in 
general  according  to  the  plan  outlined  above,  and  have  been  dis- 
charged alive.  (Table  \~'l.) 

1  Sec  also  Causes  of  Death  in  Section  I,  p.  fi-1 ;  the  Fatal  Cases  of  1'JKi,  p.  330,  and 
Ca.-c.1.-  rnsiicressfuily  Treated  l>y  Fasting,  p.  3.10. 


TREATMENT  OF   ACID  INTOXICATION 


389 


TABLE  172. — -RECOVERY  OF  CASES  THREATENED  WITH  COMA. 
No  ALKALIS  EMPLOYED. 


Case  Xo. 

7tl,-wwl  rvi        Alveolar  air 
Date.                      FcCl.                 XI  h.          |     mm   Hg              C°2' 

983     ....        Feb. 
(sec  p.  114) 

1,  1910            ++                  4 

2                        ++                 4 

4 
2 

23 

22 

3                     +  +  +              4 

0 

25 

1209     Jan. 

2,  1917 

32                   24 

(see  p.  402) 

i 

780                                 June 

11,  1910           +  +                 3 

9 

i  K  /on 

(see  ]).  217> 

12                         +                   3 

2                   24                   21 

14                        81.                   2 

o               : 

55                  25 

705     ....       Dec. 

0,  1915         +  +  +              3 

3' 

21 

(sec  p.  314)         :    Jan. 

24,  1910       +  +  +  +            2 

0 

21 

25                    +  +  +              2 

0 

24 

942     July 

12,  1910                                     4 

4                   20                  20 

(see  p.  395) 

13                       ++                 3 

~ 

17 

900     Jan. 

5,1910       +  +  +  +            3 

~* 

25/24 

974     Jan. 

24,  1910              + 

23 

(see  p.  304) 

990     ....        Feb. 

27,  1910           ++                 1 

5 

23 

1005     ....       Mar. 

0,  1910              0                    1 

1 

22/24 

(sec  p.  347) 

1011     ....       Mar. 

29,  1910           ++                 1 

8 

23 

Apri 

13,  1910 

22/22 

1085     ....       Oct. 

30,  1910              ?                    1 

7                   28                  20 

(see  ]>.  340) 

1190     ....       Dec. 

8,  1910        +  +  +  +             4 

0-' 

21 

(see  p.  379) 

9                        +  +                  0 

0                   20                22/14 

10                    +  +  +              3 

3 

18/20 

11                         +                   3 

1                   20                   20 

12                       +  +                 3 

3 

21 

13                       +  +                 2 

0 

24 

1070     ....       June 

23,  1910           ++                 1 

9               : 

>1                   20 

(see  ]).  217) 

1103     .       .       .      .       AUK. 

9,  1910       +  +  +  +            2 

1                   22                   21 

11203    ....       Sept 

0,  1910         +  +  + 

21 

(see  p.  338) 

7                         + 

18 

Oct. 

11,  1916    '        ++                 1 

9 

22 

j 

14                         0 

20 

27                         + 

15 

3.  By  former  methods  of  treatment  in  which  alkalis  were  generally 
employed  to  combat  acid  intoxication,  G44  per  cent,  of  all  my  fatal 
cases  of  diabetes  succumbed  to  coma;  but  with  the  partial  adoption 
of  the  present  method  the  total  figures  for  my  cases  have  already 
fallen  to  00s  per  cent.,  and  for  the  fatal  cases  during  this  last  year 
to  44  per  cent.  It  should  be  noted  that  many  of  these  I  did  not 
see  for  some  months  before  death. 

1  Fourteen  hours.  2  Eighteen  hours. 

3  Acidosis  disappeared,  died  of  inanition  November  26,  1910,  siijiar-  and  acid-free. 

4  Up  to  December  1,  1915.  5  December  1,  1916. 


300  T  RE  ATM  EXT 

4.  When  such  measures  as  those  indicated  here  have  been  adopted, 
I  know  of  no  case  of  diabetes,  either  of  my  own  or  reported  in  the 
literature,  which  has  shown  a  dextrose-nitrogen  ratio  of  3.(>5  :  1. 

Far  be  it  from  me  to  say  the  present  treatment  is  ideal,  but  I 
believe  it  a  step  in  the  right  direction  and  do  not  intend  to  abandon 
it  until  I  know  of  a  case  of  diabetes  of  seven  years'  duration  in  an 
individual  of  thirty-five  years  of  age  or  over,  who  shows  an  aeidosis 
of  greater  intensity  than  that  of  Case  No.  11%  (see  p.  3<SO),  and 
recovers  through  the  help  of  some  other  method.1  I  am  led  all  the 
more  to  adhere  to  this  plan  because  of  the  following  statement  of 
Allen  in  his  Harvey  Lecture:  "Aside  from  a  possible,  very  brief 
rise  in  blood-pressure,  sodium  bicarbonate  intravenously  or  other- 
wise brings  no  visible  benefit  to  the  dog  dying  of  aeidosis." 

The  critical  period  in  the  management  of  diabetes,  so  far  as  acid 
poisoning  is  concerned,  is  that  in  which  rapid  changes  in  the  diet 
are  being  made.  There  is  seldom  cause  for  worry  if  one  of  the  four 
following  conditions  prevails:  a  positive  carbohydrate  balance,  a 
sugar-free  urine,  an  alkaline  urine,  or  a  negative  ferric  chloride  test. 
Diabetic  coma  has  appeared  to  me  to  occur  more  frequently  in 
the  period  just  prior  to  three  years  ago  than  a  generation  ago,  but 
statistics  upon  this  point  are  not  wholly  satisfactory. 

For  many  years  I  considered  this  increase  in  the  frequency  of 
coma  as  an  indication  of  improvement  in  treatment,  believing 
that  acid  intoxication  only  occurred  when  diabetes  had  advanced 
to  that  final  stage  where  the  tolerance  for  carbohydrate  had  nearly 
or  entirely  disappeared.  ( 'oma  would  then  be  the  logical  end  of  the 
disease.  Such  a  view  today  is  untenable  for  three  reasons:  diabetic 
coma  often  occurs  as  an  accident  in  diabetes,  being  obviously  pre- 
cipitated by  some  trivial  cause  in  a  patient  whose  malady  has 
plainly  not  run  its  course.  Investigation  of  such  instances  usually 
discloses  that  in  some  way  or  other  there  has  been  a  sudden  decrease 
of  available  carbohydrate  or  a  marked  increase  in  the  consumption 
of  fat.  It  is  immaterial  whether  the  carbohydrate  has  been  with- 
drawn from  the  diet  or  from  the  body  in  the  form  of  glycogen,  or 
whether  the  fat  was  administered  in  the  diet  or  consisted  of  body 
fat.  The  most  common  cause  for  diabetic  coma  has  probably 
been  the  sudden  change  to  a  protein-fat  diet  with  the  elimination 
of  carbohydrate.  It  little  matters  whether  this  has  been  by  design 
or  accident. 

A  second  reason  for  giving  up  the  view  that  diabetic  coma  is 
the  logical  end  of  the  disease  is,  thanks  to  Dr.  Allen  more'  than  to 
anyone  else,  the  demonstration  that  acid  intoxication  in  an 

1  J)r.  (loyelin  toils  mo  (Juno,  1017)  that  OIK-  of  his  patients  with  CO-  in  the  blood  of 
l.S  in  term.-  of  nun.  11^.  recovered  from  threatening  coma  without  alkalis.  I  know  of 
no  mure  successful  caac. 


TREATMENT  OF  ACID  INTOXICATION  391 

uncomplicated  case  of  diabetes  can  not  only  be  controlled,  but 
dispelled. 

The  third  reason  is  the  lack  of  proof  that  diabetes  is  "complete," 
for  without  "complete"  diabetes,  /.  c.,  diabetes  in  which  there  is  a 
dextrose-nitrogen  ratio  of  3.65  : 1,  acidosis  need  not  exist. 

The  spectre  of  threatening  diabetic  coma  should  always  haunt 
the  physician,  particularly  when  the  patient  is  .first  seen.  I  always 
make  it  a  rule,  no  matter  how  mild  the  case,  to  assure  myself  of  the 
condition  of  a  new  patient  entering  the  hospital  within  twelve  hours 
or  even  less  of  the  first  visit.  Since  I  have  made  this  invariable  rule, 
worry  over  new  patients  has  ceased,  because  if  threatening  acid 
intoxication  is  recognized  sufficiently  early,  harmful  results  can 
usually  be  avoided.  The  detection  of  the  premonitory  symptoms  is 
therefore  all-important.  It  is  astonishing  how  insidiously  coma 
steals  over  a  patient,  and  I  have  given  up  expecting  nurses,  unless 
they  have  had  great  experience  with  diabetic  patients,  to  recognize 
its  approach.  1  )espite  the  only  too  large  number  of  cases  of  diabetic 
coma  which  I  have  seen  myself,  more  than  once  I  have  been 
chagrined  at  having  failed  to  realize  its  onset.  Any  occurrence  out  of 
the  ordinary  should  arouse  suspicion,  and  one  should  instantly  inves- 
tigate any  of  the  following  symptoms:  anorexia,  nausea,  vomiting, 
restlessness,  unusual  fatigue,  excitement,  vertigo,  tinnitus  aurium, 
drowsiness,  listlessness,  discomfort,  painful  or  deep  breathing. 

The  soft  eyeball  in  diabetic  coma  is  a  sign  of  considerable  value. 
It  was  originally  described  by  Krause1  and  lately  its  importance 
emphasized  by  Hiesman.2  It  is  not  due  to  blood-pressure  changes 
nor  is  it  agonal,  for  it  is  not  present  in  persons  dying  from  other 
causes.  Krause  observed  it  in  22  cases  of  coma.  I  have  repeatedly 
observed  it  in  coma  and  have  noted  its  absence  in  coma  of  non- 
diabetic  origin.  In  1  of  the  3  cases  of  Schiiltz,  she  observed  that 
recovery  took  place. 

Prevention.  —  The  development  of  acid  poisoning  should  be 
prevented.  Various  agencies  can  be  invoked,  but  the  most  important 
of  all  is  that  which  will  bring  about  an  improvement  in  the  tolerance 
for  carbohydrates. 

(a)  Improvement  in  the  Toleration  for  Carbohydrates.- — It  makes 
no  difference  how  this  is  brought  about,  whether  by  fasting,  a  low 
diet,  the  exclusion  of  fat,  the  decrease  of  protein,  or  the  gradual 
elimination  of  carbohydrates.  So  soon  as  carbohydrates  begin  to 
be  assimilated  in  increasing  quantity,  the  opportunity  for  acidosis 
declines.  All  that  has  been  said  about  the  treatment  of  the  disease 
as  a  whole  applies  here.  The  chance  for  improvement  of  many  a 
diabetic  patient  in  the  past  has  been  shattered  by  the  physician 
forgetting  that  the  best  way  to  prevent  or  overcome  acid  poisoning 

1  Krau.se:   Verb.  d.  XXI  Kon<:.  f.  inn.  Mod.,  1904,  p.  439. 

2  Reisman:  Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  p.  !S5. 


o!-)l2  TRKATMKXT 

is,  first  and  foremost,  the  treatment,  of  the  diabetes  itself,  and  only 
subsidiarily  the  aeidosis.  Some  years  ago  Liithje  remarked,  with 
much  truth,  that  one  need  not  worry  about  aeidosis  when  sugar  is 
absent  from  the  urine,  and  this  I  impress  upon  patients.  Treat  the 
diabetes  and  the  aeid  poisoning  will  take  eare  of  itself. 

(I))  Elimination  of  the  Source  of  Supply  of  Acid  Bodies.— If  the 
source  of  the  aeid  bodies  in  diabetes  is  eliminated  a  long  step  is 
taken  toward  the  prevention  of  aeid  intoxication.  /3-oxybutyric 
acid  and  its  derivatives  are  formed  chiefly  from  fat,  but  also  from 
protein.  It  is  therefore  incumbent  upon  the  physician  to  provide 
that  first  of  all  the  fat  and,  when  urgent,  the  protein  are  removed 
from  the  diet  not  only  whenever  acid  poisoning  exists,  but  also  when 
it  is  suspected  that  it  may  appear. 

This  is  likely  to  happen  whenever  radical  changes  in  the  diet 
are  made,  particularly  in  long-standing  cases  of  diabetes.  Woe 
to  the  doctor  who  tries  to  treat  diabetes  of  ten  years'  duration  in  a 
radical  fashion,  lint  this  same  precautionary  measure  should 
be  adopted  in  another  group  of  cases,  namely,  with  those  patients 
who  are  especially  susceptible  to  acid  poisoning.  To  this  class 
belong  patients  with  vulnerable  kidneys,  children  not  accustomed 
to  fat,  patients  suffering  from  systemic  or  local  infection,  even 
though  mild  in  character,  obese  individuals,  and  operative  cases 
because  of  the  attendant  excitement,  trauma  and  narcosis. 

This  omission  of  fat  and  protein  need  not  be  for  long.  Soon  the 
protein  can  be  returned  and  subsequently  the  fat.  If  the  patient 
is  not  sugar-free,  fasting  should  be  instituted.  A  case  of  diabetes 
even  of  the  severest  type  can  become  acid-free  by  this  method,  when 
combined  with  fasting,  and  subsequently  take  100  grams  of  fat 
with  impunity. 

It  is  clearly  not  the  fat  j>rr  ,sr  which  is  harmful,  but  the  sudden- 
ness with  which  the  ratio  of  fat  and  carbohydrate  in  the  diet, 
whether  in  health  or  disease,  is  changed.  Six  grams  of  fat  in  an  egg 
were  given  to  a  diabetic  child,  recently  made  sugar-free,  and  caused 
an  alarming  aeidosis,  but  a  few  weeks  later  the  same  child  thrived 
on  .">()  grams  of  fat  a  day.  (See  p.  4S.~.) 

(c)  Administration  of  Substances  which  Favor  the  Combustion  of 
Acid  Bodies.-— For  many  years  the  sudden  change  from  a  diet  poor 
in  carbohydrate  to  one  rich  in  carbohydrate  has  been  observed  to 
occasionally  result  in  the  apparent  decrea.se  of  acid  poisoning.  Von 
Xoorden  employed  the  oatmeal  cure  for  this  purpose,  and  I  think 
all  must  allow  that  desperate  cases  of  diabetes  have  been  rescued 
from  immediate  coma  by  such  means.  It  is  a  question,  however, 
whether  this  improvement  has  been  due  to  the  better  oxidation 
of  the  oatmeal  during  such  a  cure,  or  secondarily  to  the  retention 
ot  body  fluid  which  it  involves.  Then,  too,  there  is  always  the  possi- 
bility of  the  decrease  in  urinary  aeidosis  being  simply  apparent 


TREATMENT  OF  ACID  INTOXICATION  393 

and  due  to  a  diminished  excretion  of  urine.  The  evidence  accu- 
mulated is  not  extensive  enough  to  settle  this  point.  Experiments 
referred  to  by  Falta,1  as  well  as  several  experiments  conducted  at  the 
Nutrition  Laboratory  suggest  that  upon  the  last  days  of  an  oatmeal 
cure  a  certain,  although  not  large,  amount  of  carbohydrate  is  burned, 
as  shown  by  the  rise  in  the  respiratory  quotient,  which  is  our  best 
evidence  upon  this  point.  This  rise  in  the  quotient  is  so  slight  when 
compared  with  the  clinical  effect  sometimes  obtained  from  oatmeal 
that  it  hardly  seems  probable  that  the  two  stand  in  relation.  It 
certainly  does  not  seem  rational  to  give  a  diabetic  patient  with  a 
blood  sugar  three  times  that  of  a  normal  individual  still  more  carbo- 
hydrate, and  I  hesitate  to  do  this.  On  the  other  hand,  if  the  blood 
sugar  is  low  and  nearly  within  normal  limits  and  the  acidosis  is 
increasing,  the  administration  of  150  grams  oatmeal  (100  grams 
carbohydrate)  or  100  grams  of  levulose  might  be  indicated.  For  the 
present,  bedside  clinical  experience  must  settle  the  question  and 
incomplete  laboratory  data  should  not  be  given  undue  weight. 
(See  Cases  Xos.  1196  and  032,  pp.  380  and  381.) 

The  administration  of  alcohol  was  shown  by  Neubauer2  to  decrease 
the  acidosis  of  a  diabetic  patient,  but  this  writer  pointed  out  that 
it  did  not  have  this  effect  in  health.  Allen,  in  his  early  report  of 
severe  cases  treated  with  fasting,  utilized  alcohol  for  this  purpose, 
desiring  to  avail  himself  of  every  means  which  had  been  advocated 
with  reason  to  combat  acidosis.  I  understand  that  in  later  cases 
he  has  employed  it  less.  My  experience  has  not  been  encouraging 
and  I  have  prescribed  it  but  little.  My  data  do  not  show  whether  its 
use  is  advantageous  or  not,  but  my  impression  is  that  it  is  not  of 
great  value.  I  give  it,  if  it  is  a  comfort  to  the  patient,  but  always 
bear  in  mind  the  possibility  that  it  will  upset  the  stomach,  which 
it  frequently  does,  and  often  wonder  whether,  when  given  during 
fasting,  it  may  not  have  an  injurious  action  upon  the  cells  of  the 
liver  and  pancreas.  If  used  at  all,  it  should  be  well  diluted.  It  can 
l)e  given,  according  to  the  taste  of  the  patient,  in  the  form  of  whisky, 
brandy  or  the  sugar-free  wines,  a  list  of  which  will  be  found  on 
pages  51G  and  517.  Dr.  John  R.  Williams,  of  Rochester,  showed  me 
a  patient  who  was  apparently  brought  out  of  impending  coma  by 
the  use  of  whisky  and  honey.  It  should  be  remembered  that  for 
every  30  c.c.  of  whisky  given  a  patient  the  combustion  of  12  grams 
fat  may  be  prevented,  granting  alcohol  and  fat  act  in  an  isodynamic 
manner.  It  is  possible  that  it  will  be  eventually  shown  that  the 
effect  of  alcohol  in  reducing  acidosis  is  simply  that  due  to  its  sub- 
stitutive  caloric  value  for  fat,  thus  reducing  materially  the  source 
of  acid  formation. 

The  favorable  effect  of  the  administration  of  carbohydrate  in  the 

1  Bernstein  and  Falta:   Deutsch.  Arch.  f.  klin.  Mod.,  1916,  cxxi,  p.  95. 

2  Neubauer:  Miinch.  mcd.  Wchnschr.,  1SS2,  v,  p.  346. 


394  T  RE  ATM  EXT 

prevention  of  coma  has  been  recorded  by  Epstein  and  Felsen.1 
1  pon  the  first  day  70  "Tarns  carbohydrate  in  the  form  of  skimmed 
milk  and  5  per  cent,  vegetables  were  given  and  subsequently  oO 
grams  carbohydrate. 

It  would  be  fortunate  for  the  diabetic  patient  if  the  researches 
started  by  Schwartz2  might,  have  been  continued.  He  found  in 
glnconic  acid  a  substance  which  was  capable  of  combustion  by  the 
diabetic,  and  as  a  result  an  existing  acidosis  could  be  'decreased., 
Unfortunately,  this  substance  is  not  available,  due  in  great  part  to 
the  expense  of  production.  1  know  of  no  other  substitute  for 
carbohydrate  which  has  this  antiketogenic  function. 

(<7)  Dangers  of  Alkalis. — The  dangers  attendant  upon  the  use 
of  alkalis  in  the  treatment  of  acid  intoxication  far  outweigh  their 
advantages.  This  is  a  strong  statement,  but  experience  has  forced 
this  confession  from  me.  I  believe  that  often  a  patient  threatened 
with  diabetic  coma  is  sent  into  actual  coma  by  the  careless  adminis- 
tration of  alkalis.  Between  September  22, 191"),  and  March  12,  1917, 
but  ?•>  of  the  cases  of  diabetes  in  hospitals  under  my  care  have 
received  alkali  in  any  form.  During  April  and  May,  191C>,  I  gave 
a  total  of  44  grams  to  one  patient  and  20  grams  to  another.  One 
of  the  three  patients  had  been  receiving  alkalis  prior  to  entrance 
and  I  hesitated  to  suddenly  omit  the  soda  and  thus  disturb  the  water 
balance  of  the  body.  These  three  patients  all  died  of  coma.  The 
results  obtained  since  the  routine  administration  of  alkalis  has  been 
abandoned  have  been  so  satisfactory  that  T  shall  not  willingly  return 
to  their  employment.  A  diabetic  patient  theoretically  needs  alkalis. 
\Vilenko,:!  has  shown  that  glycolysis  in  blood  and  organs  is  hampered 
when  the  blood  becomes  even  a  trifle  less  alkaline  than  normal. 
Hut  one  must  bear  in  mind  that  it  is  possible  that  the  administra- 
tion of  small  quantities  of  an  alkali  over  long  periods  may  set  free 
acid  bodies  existing  combined,  quiescent  and  harmless  in  the  body, 
and  thus  do  harm.  Furthermore,  the  administration  of  alkalis 
over  long  periods  may  deplete  the  body  salts,  such  as  chlorides, 
which  are  distinctly  useful.  Another  danger  from  the  use  of  alkalis 
is  the  occurrence  of  nausea  and  vomiting,  and  this  is  real,  though 
greatly  lessened  when  chalk  is  combined  with  the  sodium  bicarbon- 
ate. When  alkalis  are  given  large  quantities  of  urine  must  be  voided 
to  remove  the  salts  of  the  acid.  The  quantity  of  liquid  which  must 
be  ingested  is  so  large  as  to  overburden  the  stomach  and  the  excre- 
tion of  so  much  acid  frequently  overwhelms  the  kidneys  and  they 
cease  to  act. 

Finally,  the  constant  use  of  an  alkali  appears  to  promote  the 

1  Epstein  and  Folson:    Am.  Jour.  Mod.  S<\,  1917,  ciliii,   p.  OS. j 

2  Schwartz:    Dcut.  Arch.  f.  klin.  Med.,  I'M).'!,  Ixxvi,  p.  247. 
'  Wilunko:   Med.  Klin.,  Berlin,  l'Jl-1,  x,  p.  1003. 


TREATMENT  OF  ACID  INTOXICATION  395 

constant  excretion  of  acid  bodies.  I  have  known  a  moderate  acid- 
osis  of  months'  duration  to  vanish  with  the  omission  of  soda.  It 
is  frequently  to  be  observed  that  when  an  alkali  is  omitted  in  the 
convalescent  stages  of  a  diabetic  cure  that  acidosis,  as  measured 
by  the  urine,  entirely  disappears,  but  will  be  brought  back  by 
resuming  the  alkali.  A  very  small  quantity  of  alkali  may  cause  the 
appearance  of  a  positive  ferric  chloride  reaction  in  the  urine. 
Patients  have  observed  this  after  a  Seidlitz  powder,  and  one  patient, 
Case  Xo.  942,  thought  it  followed  the  use  of  a  brand  of  saccharine 
which  was  combined  with  sodium  bicarbonate.  In  other  words,  the 
administration  of  an  alkali  may  give  a  false  idea  as  to  the  severity 
of  the  case  if  one  is  guided  by  the  urine  alone.  This  shows  how 
necessary  it  is  to  study  the  blood.  Van  Slyke  in  the  discussion 
of  a  paper  by  Fitz  at  the  Association  of  American  Physicians  in  May, 
1917,  pointed  out  that  not  only  acids  remaining  in  the  body  might 
do  harm  but  also  those  excreted  in  the  urine  by  removing  bases. 
It  is  by  no  means,  therefore,  an  unmixed  blessing  to  favor  the  re- 
moval of  acids  from  the  body  by  the  use  of  alkalis. 

A  few  years  ago  I  wrote  the  following  sentence:  "Few  instances 
in  medicine  occur  which  show  more  strikingly  the  benefit  of  the 
administration  of  a  drug  than  the  change  from  the  drowsiness  and 
exaggerated  respiration  of  beginning  diabetic  coma  to  the  reawaken- 
ing which  follows  the  administration  of  large  doses  of  sodium 
bicarbonate."  Since  I  have  given  up  alkalis  I  have  seen  fully  as 
drowsy  patients  recover  without  their  use.  In  the  ordinary 
treatment  of  diabetes  alkalis  are  certainly  not  needed.  It  is  safer, 
more  agreeable  to  the  patient,  and  easier  to  bring  about  the  dis- 
appearance of  a  slight  or  moderate  acid  intoxication  by  the  omission 
of  fat  followed  by  fasting  than  to  attempt  to  neutralize  acid  intoxi- 
cation with  an  alkali. 

In  earlier  days  when  alkalis  were  given  to  diabetic  patients  as  a 
matter  of  routine  it  was  found  better  to  administer  the  same  in 
fairly  large  doses,  6  to  8  grams  six  times  a  day,  and  after  continuing 
this  amount  for  three  or  four  days  to  gradually  decrease  the  quantity. 
The  clinical  experience  of  various  authors,  as  well  as  my  own, 
favored  the  administration  of  doses  fully  as  large  as  this,  rather 
than  to  begin  with  small  doses  and  then  increase  the  same.  Possibly 
the  reason  for  this  was  that  by  this  means  alkalis  were  given  over 
a  shorter  period  of  time  and  the  total  amount  was  less,  so  that  the 
good  accomplished  was  not  offset  by  the  harm  of  prolonged 
administration. 

If  alkalis  are  employed  they  should  be  administered  in  dilute 
form  both  to  avoid  irritation  of  the  gastro-intestinal  tract,  and  to 
favor  the  ingestion  of  large  quantities  of  liquid.  The  greatest  pains 
should  be  taken  not  to  give  an  alkali  for  several  hours  before  or  after 


306  TREATMENT 

acid  fruits.  Generally,  the  stomach  tolerates  alkali  better  when 
not  given  within  an  hour  of  alcohol,  so  that  when  alcohol  and 
alkalis  are  given  freely  it  is  best  to  alternate  the  same.  It  is  undesir- 
able to  give  alkalis  in  milk,  because  nausea  and  vomiting  may  result, 
and  nothing  is  more  harmful  in  severe  acid  intoxication  than  the 
production  of  vomiting.  Rather  than  bring  a  patient  to  this  stage, 
give  up  all  medication  by  the  mouth.  A  quart  bottle  of  Celestins 
Vichy  contains  approximately  4  grams  of  sodium  bicarbonate, 
and  patients  are  often  glad  to  take  their  alkali  in  this  form.  In 
some  cases  an  additional  4  grains  or  more  of  the  bicarbonate  may 
be  added  to  the  chilled  Vichy. 

It  is  generally  agreed  that  the  sodium  salts  are  preferable  to 
the  potassium  salts  if  the  doses  given  are  to  be  large.  Sodium 
bicarbonate  was  the  alkali  most  commonly  and  advantageously 
used  in  my  practice.  Sodium  citrate  is  of  the  same  bulk  as  the 
bicarbonate,  is  said  to  be  less  irritating  because  carbon  dioxide 
is  not  set  free  in  the  stomach,  less  apt  to  cause  diarrhea  and  less 
disturbing  to  the  appetite,  but  I  have  not  found  that  it  made 
much  difference  which  preparation  the  patient  used.  The  citrate 
is  said  to  be  oxidized  in  the  body  and  in  this  oxidation  to  favor  the 
combustion  of  acid  products,  but  I  question  whether  this  property 
is  of  enough  importance  to  outweigh  the  advantages  of  the  use  of 
sodium  bicarbonate,  which  can  be  so  easily  obtained. 

Sodium  carbonate  is  too  irritating,  and,  furthermore,  on  account 
of  the  water  of  crystallization,  the  actual  amount  of  sodium  which 
is  contained  in  100  grams  of  sodium  carbonate  is  equivalent  to 
only  5S  grams  of  the  bicarbonate.  This  is  not  generally  recognized. 

Magnesium  citrate  is  an  excellent  preparation  when  constipation 
is  associated  with  the  acidosis,  but  naturally  large  amounts  cannot 
be  given  in  this  form. 

( 'halk,  calcium  carbonate  (creta  preparata)  is  valuable  because  it 
will  not  only  act  as  an  alkali,  but  because  it  tends  to  render  the 
sodium  bicarbonate  less  irritating  to  the  stomach  and  thus  is  less 
apt  to  cause  nausea  or  diarrhea. 

Alkali  may  be  given  by  the  rectum  in  the  form  of  a  3  per  cent, 
solution  of  sodium  bicarbonate  in  salt  solution.  This  is  occasion- 
ally well  borne,  but  I  attach  so  much  importance  to  the  liberal 
administration  of  liquids  that  I  always  hesitated  to  use  the  rectum 
for  alkaline  medication.  There  is  too  much  danger  of  its  becoming 
intolerant  for  any  kind  of  fluid. 

Sodium  bicarbonate  may  also  be  given  intravenously.  I  nfor- 
tunately,  at  times  following  the  intravenous  administration  of 
sodium  bicarbonate,  convulsions  and  collapse  occur,  so  that  one 
dislikes  to  resort  to  this  method  if  others  will  suffice.  It  is  my 
impression  that  if  the  intravenous  method  were  adopted  freely  at 


TREATMENT  OF  ACID  INTOXICATION  397 

the  beginning  of  threatening  symptoms,  the  alkali  treatment  of 
coma  would  be  much  more  successful.  The  harmful  effects  attrib- 
uted to  the  intravenous  injection  of  alkalis  may  in  part  be  connected 
with  the  late  stage  at  which  they  are  given.  Sodium  bicarbonate 
is  the  best  form  of  alkali  to  give  intravenously,  and  although  10 
per  cent,  solutions  have  been  given,  it  is  probably  safer  to  use  a 
3  per  cent,  solution,  and  to  give  a  liter  of  the  same  and  repeat  it 
within  twenty-four  hours.  I  gave  1500  c.c.  of  such  a  solution  several 
times  to  Case  No.  4,  with  the  result  that  he  came  out  of  coma  only 
to  relapse  into  it.  Young  individuals  present  a  better  prognosis  than 
adults  and  much  better  than  elderly  individuals  with  damaged 
kidneys.  Blum  suggests  that  a  second  injection  be  avoided  unless 
increased  diuresis  has  shown  that  the  body  was  capable  of  dealing 
with  the  first. 

The  sodium  bicarbonate  may  be  sterilized  along  with  the  salt 
solution.  It  is  true  that  some  of  the  carbon  dioxide  is  liberated 
through  sterilization,  but  this  does  no  harm  when  injected  intra- 
venously. Under  no  conditions  should  soda  solution  be  given  sub- 
cutaneously.  Magnus-Levy1  pointed  out  that  if  a  current  of  carbon 
dioxide  should  be  passed  through  the  solution  of  sodium  bicarbonate 
after  it  has  been  sterilized  and  the  sodium  carbonate  has  been 
precipitated  until  the  red  tint  with  phenolphthalein  disappears  the 
sodium  bicarbonate  would  be  reformed.  Sterilization,  however, 
is  probably  not  necessary.  My  former  assistant,  Dr.  F.  A.  Stan- 
wood,  demonstrated  by  a  series  of  experiments  that  if  sodium  bicar- 
bonate was  taken  with  a  sterile  spoon  from  a  previously  unopened 
Squibb's  package,  weighed  in  a  sterile  watch-glass,  and  then  added 
to  sterile  salt  solution,  the  resulting  solution  was  sterile.  He  also 
found  that  if  infected  with  staphylococci  and  typhoid  bacilli  the 
solution  sterilized  itself  in  three  days. 

(?)  Importance  of  Liquids. — A  study  of  recovery  from  coma  in 
diabetes  invariably  shows,  so  far  as  I  am  aware,  that  large  quanti- 
ties of  urine — frequently  10,000  c.c.  daily  for  several  days — were 
voided  in  old  days  when  the  alkaline  treatment  was  employed. 

Seldom  if  ever  does  diabetic  coma  occur  in  a  patient  showing 
considerable  edema  unless  severe  cardiac  or  renal  trouble  is  also 
present.  The  exclusion  of  salt  from  the  diet  of  the  severe  diabetic 
patient  apparently  hastens  coma,  and  it  is  possible  that  the  adminis- 
tration of  a  diet  poor  in  salts  for  long  periods  may  be  harmful  for 
this  reason.  Conversely,  the  favorable  effect  of  some  mineral 
waters  may  possibly  be  attributed  to  the  large  quantity  of  salts 
which  they  contain.  It  occasionally  happens  that  a  case  of  diabetic- 
coma  is  rescued  by  the  free  use  of  salt  solution.  All  these  observa- 

1  Magnus-Levy:  Therap.  Monatschr..  1913,  xxvii,  p.  838. 


398  THE  AT  ME  XT 

tioiis  point  to  the  importance  of  having  the  diabetic  patient  secure 
liquids  in  abundance. 

Hut  it  is  not  enough  to  offer  diabetic  patients  liquids.  The  liquids 
must  be  given  in  such  form  that  they  will  be  retained.  A  stomach 
bombarded  alternately  with  alcohol  and  soda  each  hour  will  not 
tolerate  even  plain  water  long.  Recourse  should  be  had  to  rectal 
injections  of  salt  solution  early  rather  than  late.  The  salt  solution 
may  be  given  intravenously  provided  it  is  given  slowly.  Only  once 
have  I  known  of  salt  solution  being  given  subcutaneously  to  a 
diabetic  without  causing  an  abscess. 

In  giving  salt  solution  one  must  be  careful  not  to  give  so  much 
as  to  embarrass  the  kidneys  in  excreting  the  salt.  Taj)  water  may 
be  given  alternately  with  salt  solution. 

J.     THE  CONSERVATION  OF  ENERGY  IN  THE  DIABETIC 
INDIVIDUAL. 

The  untreated  severe  diabetic  loses  much  energy  through  unoxi- 
di/ed  products  (sugar  and  /3-oxybutyric  acid)  voided  in  the  urine, 
and  by  his  increased  metabolism.  Every  effort  should  be  made  to 
prevent  this  waste,  and  this  is  accomplished  by  the  treatment  above 
outlined.  So  soon  as  sugar  and  acid  disappear  from  the  urine  the 
metabolism  falls.  Patients  upon  a  low  diet,  should  avoid  extremely 
low  temperatures  as  well  as  rapid  reductions  in  body  heat, 
which  occur  in  automobiling  or  in  prolonged  cold  bathing.  So 
soon  as  sufficient  calories  can  be  given,  and  the  body,  by  treatment, 
is  brought  back  into  good  physical  condition,  the  necessity  for  these 
precautions  disappears.  There  is  another  loss  of  heat  not  generally 
appreciated.  Patients  drink  cold  water,  and  this  must  be  raised 
to  the  temperature  of  the  body  before  it  is  excreted  as  urine.  The 
amount  of  energy  expended  in  warming  this  water  is  considerable. 
Thus  if  three  liters  (kilos)  of  water  at  10°  ('.  (;">()°  F.)  are  drunk,  the 
temperature  must  be  raised  to  :>7°  ('.,  (l>X.<i°  F.),  an  increase  of 
27°  ('.  Since  1  calorie  is  necessary  to  raise  the  heat  of  I  kilo  of 
water  1°  ('.,  to  raise1  )>  kilos  of  water  1*7°  (\,  there  would  be' 
required  SI  calories.  In  oilier  words,  the  patient  has  employed 
enough  energy  in  raising  the  temperature  of  this  liquid  to  that  of 
body  heat  to  convert  approximately  two  pounds  of  water  at  0°  (\ 
into  boiling  water.  Body  heat  is  also  lost  by  the  large  quantities 
of  liquids  drunk  and  water  voided.  Thus  < !()()()  c.c.  of  urine  would 
represent  a  loss  of  approximately  "200  to  -\00  calories.  The  loss  of 
energy  could  also  be  prevented  by  limitation  of  exercise.  But  it  has 
already  been  pointed  out  that  there  are  objections  to  such  a  course. 
\\hile  it  is  true  that  exercise  favors  the  oxidation  of  carbohydrates, 
there  is  alwavs  danger  that  the  exercise  mav  be  overdone  unless  the 


THE   USK  OF  DRUVX  399 

patient  is  prepared,  as  lie  should  be,  for  it.  Even  cases  of  diabetes  of 
moderate  severity  should  not  enter  into  contests  or  place  themselves 
in  other  situations  where  they  cannot  instantly  rest  if  the  need  is  felt. 
Case  No.  344,  who  was  a  model  patient,  and  withstood  his  severe 
diabetes  for  years,  exercised  quite  freely,  both  horseback  riding  and 
at  tennis,  but  he  invariably  exercised  for  short  periods  and  took  a 
complete  rest  immediately  afterward.  lie  was  able  to  live  up  to  a 
rule  of  Dr.  F.  C.  Sbattuck  that  one  hour  after  the  exercise  ceased 
the  patient  should  feel  better  than  before  it  was  begun. 

Attention  has  already  been  called  to  the  need  of  maintaining  the 
body  warmth  of  patients  threatened  with  diabetic  coma.  Just  as 
much  pains  should  be  taken  to  avoid  exposure  of  such  a  patient  as 
is  taken  with  patients  suffering  from  acute  Bright's  disease. 

K.     THE  USE  OF  DRUGS. 

Drugs  may  be  very  beneficial  in  the  course  of  treatment  of  a 
diabetic  case,  as  in  any  chronic  disease,  but  this  is  not  because 
of  any  specific  action  upon  the  diabetes.  Nevertheless,  scores  of 
drugs  have  been  employed  with  such  a  purpose.  I  use  none  of 
them,  and  I  think  the  same  custom  is  followed  by  those  who  have 
had  a  greater  series  of  cases.  The  older  writers  considered  opium 
with  its  derivatives  and  jambul  and  aspirin  the  best  of  the  drugs. 
Even  these  drugs  fail  to  increase  the  tolerance  of  the  patient  for 
carbohydrates  more  than  temporarily.  A  good  rule  to  follow  in 
regard  to  drugs  for  diabetics  is  that  of  Ralph  Waldo  Emerson  for 
novels — wait  a  year.  This  saved  me  once  from  giving  corrosive 
sublimate  to  Case  No.  1. 

The  employment  of  drugs  by  the  profession  is  far  too  common. 
Why  this  should  be  so,  when  men  like  Naunyn,  von  Noorden,  and 
Hodgson,  with  an  enormous  experience  in  diabetes,  discountenance 
drugs,  deserves  analysis.  The  chief  reason  for  this  which  I  have 
heard  was  that  the  patient  could  not  be  controlled,  and  will  not  be 
satisfied  unless  he  is  given  medicine.  1  have  had  no  trouble  upon  this 
score.  The  reason  why  it  is  hard  to  retain  the  patient's  confidence 
is  not  that  drugs  are  not  given,  but  that  results  are  not  obtained 
with  the  diet  prescribed.  A  properly  devised  diet  will  keep  the 
patient  in  hand  better  than  all  the  drugs  in  the  pharmacopu'ia.  A 
proper  diet  implies  that  the  urine  has  been  examined  and  the  carbo- 
hydrate, protein  and  fat  in  the  diet  for  the  corresponding  period 
reckoned. 

It  is  my  impression  that  physicians  who  use  drugs  the  most  are 
those  who  examine  the  urine  quantitatively  the  least. 

If  one  wishes  to  know  the  effects  of  a  drug  upon  the  course  of 
diabetes  a  careful  metabolism  experiment  should  be  carried  out. 


400  TREATMENT 

The  patient  should  be  put  upon  a  constant  diet  and  maintain  this 
for  a  period  of  at  least  fifteen  days.  During  the  middle  five  days 
the  drug  would  be  administered,  while  the  preliminary  and  after- 
periods  should  serve  as  controls.  It  would  really  be  advisable  to 
have  the  experiment  last  twenty  days,  so  that  the  drug  could  be 
given  during  one  of  the  middle  five-day  periods,  thus  concealing  its 
administration,  in  order  to  discount  any  mental  effect.  Such  an 
experiment  would  at  least  give  a  hint  of  the  value  of  a  drug. 
From  a  considerable  experience  with  metabolism  experiments  in 
diabetes  I  must  add  that  data  of  this  sort  can  only  be  satisfactorily 
collected  when  the  patient  is  under  close  supervision.  Even  with 
the  best  of  intentions  to  cooperate  in  the  test,  the  patient  may  break 
the  prescribed  diet  without  knowing  it. 

Finally,  before  resorting  to  such  drugs  as  opium  or  aspirin  one 
should  consider  the  probable  duration  of  life  of  the  particular  patient 
under  dietetic  treatment.  If  such  consideration  shows  that  the 
patient  has  a  good  prospect  of  living  ten  years,  advice  to  use  opium 
would  be  very  different  from  such  advice  if  the  expectation  of  life 
was  ten  months,  ten  weeks,  or  ten  days.  The  older  plan  of  treat- 
ment with  drugs  lost  sight  of  this.  The  perspective  was  too  narrow. 
Thus  Case  Xo.  10,  male,  bank  teller,  came  to  me  in  October,  1899, 
with  the  history  of  onset  of  diabetes  at  thirty-nine  years  of  age, 
March,  1S9S,  while  on  an  important  financial  trip  to  New  York  City. 
The  urine  contained  S.I  per  cent,  sugar,  and  with  moderate  restriction 
of  carbohydrates  showed,  four  days  later,  a  moderate  ferric  chloride 
reaction  and  3.4  per  cent,  sugar.  For  weeks  previous  to  his  visit 
to  me  he  had  taken  large  quantities  of  opium,  and  had  reached  a 
most  deplorable  condition  until  he  gave  it  up  of  his  own  accord. 
It  is  true  that  he  became  sugar-free  only  for  a  few  days,  with  the 
treatment  of  eighteen  years  ago,  but  for  the  succeeding  twelve  years 
he  not  only  continued  his  occupation,  but  was  promoted  to  the 
position  of  cashier,  only  giving  up  work  in  1909  upon  development 
of  mild  signs  of  pulmonary  tuberculosis.  The  utter  impracticability 
of  treating  such  a  case  for  twelve  years  with  opium  is  obvious. 

Opium  may  decrease  the  sugar  in  the  urine  by  about  1  per  cent., 
if  it  has  already  fallen  to  the  vicinity  of  2  per  cent.  The  quantity 
of  sugar  is  seldom  lowered  more  than  10  to  15  grams,  and  at  the 
most  only  15  to  '20  grams.  Small  doses  of  opium  are  not  efficacious, 
and  the  larger  doses,  /.  c.,  5  to  7  grains,  exert  too  injurious  an 
influence  to  be  continued  more  than  for  a  short  time.  Von  Noorden 
occasionally  uses  opium  temporarily,  but  never  for  more  than  two 
weeks.  Kleiner  and  Meltzer,1  following  the  use  of  rather  large  doses 
of  morphin  to  dogs,  found  the  elimination  of  intravenously  injected 

1  Kleiner  and  Meltzcr:   Proc.  Nat.  Acad.  Sc.,  1910,  ii,  p.  369. 


THE  USE  OF  DRUGS  401 

dextrose  considerably  increased  and  that  it  retarded  the  return  of  the 
sugar  content  of  the  blood  to  its  previous  level. 

Aspirin  is  still  less  advantageous  than  opium,  for  though  it 
may  be  taken  with  little  discomfort  for  a  short  period  of  time,  it 
eventually  is  sure  to  disturb  the  digestion.  No  one  pretends  that 
aspirin  will  act  after  it  is  omitted,  and  I  expect  my  patients  to 
live  too  long  to  use  it  permanently.  I  cannot  acquire  any  enthu- 
siasm for  the  other  drugs,  but  in  the  works  of  Naunyn  and  von 
Noorden  data  will  be  found  about  many  preparations  which  they 
have  investigated.  An  exhaustive  description  of  the  older  prep- 
arations will  also  be  found  in  the  article  by  Kaufmann.1 

Organic  preparations  made  from  the  pancreas  and  the  pancreatic 
gland  itself  have  been  frequently  employed,  but  thus  far  the  data 
do  not  appear  to  me  to  warrant  a  continuance  of  their  use.  So  far 
as  the  digestion  of  fat  is  concerned,  I  fear  my  patients  have  absorbed 
it  too  well. 

The  Bacillus  bulgaricus  has  been  extensively  advertised  and  tried. 
Henderson2  investigated  its  action  and  concluded  it  was  of  no 
advantage  in  the  treatment  of  diabetes. 

Caramel,  originally  recommended  by  Grafe3  was  employed  later 
by  Umber.  In  mild  or  moderate  diabetes  he  noted  no  increase  in 
the  sugar  content  of  the  urine,  but  in  severe  cases  the  glycosuria 
increased.4  It  should  not,  therefore,  be  employed  save  with  the 
same  control  as  any  carbohydrate. 

Substitutes  for  Suf/ar. — Saccharine  may  be  used  as  a  substitute 
for  sugar.  It  is  far  better,  however,  for  the  patient  to  forget  the 
sweet  taste.  Children  especially  should  grow  up  without  it,  learning 
to  depend  on  the  natural  flavors  of  vegetables  and  fruit.  If  sac- 
charine is  employed,  advise  the  patient  to  render  foods  less  sour 
with  saccharine  rather  than  to  make  them  sweet,  because  the  sweet 
taste  persists.  Foods  should  not  be  heated  after  the  addition  of 
saccharine,  as  they  are  apt  to  acquire  a  bitter  taste.  Various 
other  preparations  have  been  employed  instead  of  saccharine. 
Such  are  crystallose  and  dulcin.  Attention  is  called  to  the  possi- 
bility of  saccharine  prolonging  a  positive  ferric  chloride  reaction 
in  the  urine  if  it  is  prepared  with  sodium  bicarbonate.  So  far  as 
I  am  aware,  substitute  preparations  have  no  advantage  over 
saccharine  and  cost  more. 

Glycerin  is  not  desirable  as  a  sweetening  agent.  From  it  sugar 
may  be  formed.5 

1  Kaufmann:  Zentralbl.  f.  klin.  Mod..  1903,  xlviii.  p.  260. 
-  Henderson:  Jour.  Am.  Mod.  Assn..  1915,  Ixiv,  p.  4950. 
3Crafo:  Munch,  mod.  Wchnsohr.,  1914,  Ixi,  p.  1433. 
4  Umber:  Deutsch.  mcd.  Wvlmschr.,  1915,  xli,  p.  181. 
6  Naunyn:  Loc.  cit.,  p.  441. 


402  TREATMENT 

Hediosit, — Ilediosit,  the  lacton  of  glycoheptonic  acid,  is  a  sugar 
with  7  carbon  atoms.  It.  is  oxidi/ed  by  the  patient,  and  so  might 
be  helpful,  not  only  in  combating  acidosis,  but  to  sweeten  the  food. 
Unfortunately  it  is  expensive  and  often  disliked  by  the  patient,  and 
Linels1  has  found  that  upward  of  a  quarter  of  the  quantity  adminis- 
tered may  be  lost  in  the  stools  under  normal  conditions.  If  a  laxa- 
tive effect  is  present,  SO  per  cent,  is  thus  lost  in  addition  to  a 
portion  excreted  in  the  urine. 

L.     THE  TREATMENT  OF  COMPLICATIONS. 

The  complications  or  sequelae  of  diabetes  are  quite  as  important 
as  the  disease,  but  we  should  bear  in  mind  that  it  is  the  diabetes 
which  is  originally  at  fault  and  not  the  complication.  A  duodenal 
ulcer  may  perforate  and  cause  peritonitis,  but  the  real  cause  of  the 
death  is  the  neglected  ulcer  and  not  the  complication — peritonitis. 
It  is  the  inadequately  treated  diabetic  who  develops  complications. 
Diabetic  patients  should  remain  free  from  complications  because 
diabetics  are  or  should  be  constantly  under  the  doctor's  eye  and  his 
prophylactic  care. 

In  the  past  the  duration  of  life  of  diabetic  patients  has  been  so 
short  that  the  dangers  which  might  result  from  peculiarities  of 
treatment  have  been  neglected,  for  in  the  space,  of  five  or  six  years 
these  would  not  manifest  themselves,  but  now  with  the  duration 
of  the  disease  being  so  much  prolonged,  all  these  factors  must  be 
taken  into  account.  It  is  a  well-known  fact  that  disease  of  the 
kidneys  may  occur  in  diabetics  who  have  had  diabetes  for  many 
years.  lias  this  been  brought  about  by  the  protein-fat  diet?  Those 
interested  in  the  study  of  diseases  of  the  kidney  could  ask  no  better 
experimental  basis  for  the  investigation  of  etiological  dietetic 
problems  than  these  patients.  Here  are  experiments  of  a  most 
accurate  type  going  on  before  their  very  eyes,  not  for  days  or 
months,  but  for  years. 

1.  Infectious  Diseases. — Never  try  to  cure  the  diabetes  in  the 
presence  of  an  acute  infectious  disease.  This  is  where  the  family 
doctor  has  often  scored  on  the  supposedly  wise  consultant.  The 
latter  would  order  a  fat-protein  diet  and  death  would  result.  If 
the  case  is  doing  well,  either  leave  it  alone  or  make  gradual  changes 
and  there  will  be  more  chances  of  having  the  individual  for  a  patient 
during  years  to  come  than  as  if  brilliant  dietetic  orders  were  given. 
\\ith  my  diabetic  children,  realizing  their  tendency  to  acidosis,  I 
always  try  to  avoid  acidosis  during  an  infection  by  keeping  the  fat 
low,  otherwise  the  treatment  is  plain  sailing. 

1  Linels:  Arch.  f.  cxp.  P;n1ml.  u.  Pharin.,  HM-l,  Ixxvii,  p.  :M~>. 


TREATMENT  OF   COMPLICATIONS 


403 


Carbohydrate  in  the  form  of  oatmeal  gruel,  orange  juice  and  even 
as  puree  vegetables  and  protein  as  whites  of  eggs,  oysters  and  fish, 
will  tide  over  many  emergencies  and  it  very  likely  will  be  found  that 
the  patient  can  bear  a  moderate  quantity  of  fat  as  well.  There  is  no 
reason  for  not  giving  what  the  full  tolerance  will  allow.  Could  it 
be  that  the  tolerance  during  fever  would  not  be  lowered  if  fat  was 
restricted — in  other  words,  acidosis  avoided? 

TABLE  173. — CASE  No.  12G4.    ILLUSTRATING  How  EASILY  A  DIABETIC  DOCTOR 
BECAME  SUGAR-FREE  AND  WHAT  HAPPENED  WHEN  TONSILLITIS  DEVELOPED. 


Sugar 

Diet  in  grams. 

•i              'c.* 

in  urine 

—         ..  ^  2 

Date, 

;_' 

-r 

fs   £.*! 

Diet  ordered, 

1917. 

0 

5  - 

1 

-2 

>:    " 

r?   f*a 

gms. 

Cj 

'•*3 

'•3  5 

5 

JL  £        - 

~~    t 

-s'  -~ 

R  ~  ° 

| 

^ 

3  £ 

~ 

•ti1< 

~        ^ 

-5,     o 

Is  '£  Jsl 

>              S 

« 

•- 

•^    1  ^i 

£ 

<  c 

C        X  !5 

Spec.      v.  si.  + 

tr. 

Mar. 

S-  9 

1300  + 

0 

0.1 

1 

153  + 

80  + 

+ 

.      950 

152+    0    177 

5  per  cent,   veg.,  450; 

oranges,  3;  fish,  300; 

potato,    270;    bread, 

t  90. 

9-10 

1400 

0 

0 

1  1 

153 

98       ,      0 

0    1004 

153  + 

0 

178 

Same  as  8—9. 

10-11 

550 

0 

0 

II 

153        75 

47  ;  0  ,  1335 

153  + 

0 

179 

Make  potato  180  and 
bread  120;  add  meat, 

120;  bacon,  30;  eggs,  2 

11-12     1200              0 

0      0 

105      !  S3         47 

)    1415 

105-r    0 

Add  milk,  240. 

Tonsi  llitis  . 

12-13'  1100              0 

tr. 

0 

40        20 

IS    0      508 

40+0 

Add  oatmeal,  30. 

13-14 

800 

0 

0.1 

1 

104 

41 

10     0      090 

103  +  1  0 

Same  as  12-13. 

14-15 

700 

si.   + 

0.1 

1) 

108 

01 

2     0      534 

108+    0 

179 

Make  5  per  cent,  veg., 

300;  bread,  90;  fish, 

180;     oatmeal,      15; 

milk,  30. 

15-10 

SOO 

v.  si.  + 

0.1     2 

100 

68 

28 

0      948    104  + 

0 

174 

Omit  fish;  make  meat 

120. 

10-17     1100 

0 

0 

II 

52      ;50           3    0      435      52  + 

0 

173 

Make  potato  90;  oat- 

meal,  30;   milk,   60; 

add  fish,   ISO. 

17-18 

1300              0 

0 

1) 

77      ,  OS 

41 

)     919      77+0 

172 

Omit  fish;  make  meat 

150;  potato,  120. 

18-19     1300 

0 

0 

II 

77        71 

74 

3    1258      77  + 

0    174 

Add  butter,  30;  make 

bacon  15. 

19-20     1400              0 

0      0 

77        79         87  'o    1407      77-    0    173    Make  bacon  33;  eggs, 

3. 

20-21     1200              0 

0      0 

70      ,  79       109     0  ,  1001      70+    0    174 

Omit  milk;  add  cream, 

00. 

21-22     1000+         0 

0 

II 

70       '  79 

99    0    1511:    70+    0    173    Same  as  20-21. 

22-23       900              0 

0 

II 

70        79        109 

)    1001       70  + 

0      .  .      Same  as  20-21. 

(a)  Pneumonia. — By  no  means  do  all  diabetic  patients  die  when 
they  have  pneumonia  as  Table  174  will  show.  1  am  quite  sure  there 
have  been  other  patients  in  my  group  who  have  recovered,  for  it  is 
only  recently  that  my  attention  has  been  directed  to  this  point. 

Case  Xo.  105  recovered  from  mumps,  Case  No.  93S  from  chicken- 
pox,  and  Case  Xo.  12(>4  from  tonsillitis.  (Table  173.) 

I  have  already  referred  to  an  Italian  diabetic  at  the  Boston  City 
Hospital  who  recovered  from  typhoid  fever  upon  a  diet  of  oatmeal 
and  olive  oil.  A  patient  in  diabetic  coma  whom  I  was  asked  to  see 


404  TREATMENT 

showed  a  diphtheritic  membrane  (culture  positive)  and  died  twelve 
hours  later.  During  an  attack  of  herpes  zoster  the  carbohydrate 
tolerance  of  Case  No.  o21  fell  markedly.  This  is  interesting  because 
it  suggests  an  infectious  etiology  of  this  disease. 

TABLE  174. — RECOVERY  FUOM  PXEUMOXIA  ix  DIABETES. 


Ago  at 

Duration. 

Case 

onset  of 

Before 

After 

No. 

diabetes. 

pneumonia. 

pneumonia. 

8      .       . 

.       .       .      60  ± 

12  years  6  months 

1  year  1  month 

10      .       . 

.      .      .      47 

7  months 

9  years 

30      . 

.      .      .      42 

7  years 

3  years  3  months 

40     .      . 

.      .      .      62 

20  years 

4  months 

358 

53 

1  7  years 

1  year    3  months 

435 

3-3 

23  years 

2  months 

SOo      .       . 

55 

12  years 

12  years  2  months 

1271      .       . 

.      .      .      56 

4  years 

7  years  9  months 

2.  Tuberculosis. — Tuberculosis  formerly  was  responsible  for  about 
one-half  of  the  deaths  of  diabetic  patients,  but  today,  in  private 
practice,  it  seldom  occurs.  Montgomery,1  who  has  published  an 
excellent  critical  summary  of  the  literature  upon  diabetes  mellitus 
and  pulmonary  tuberculosis,  concludes  that  tuberculosis  is  not 
more  frequent  among  diabetics  than  among  the  rest  of  the  popula- 
tion of  similar  age.  Undoubtedly  this  is  due  to  the  well-known 
decrease  in  the  mortality  from  tuberculosis  everywhere.  Yon 
Xoorden,  writing  later  than  did  Xaunyn,  records  a  still  lower  percent- 
age among  his  cases,  though  in  Yienna  it  was  nearly  twice  as  common 
among  hospital  diabetics  as  in  Frankfort.  This  is  a  striking  illus- 
tration and  a  warning  against  exposure  of  diabetic  patients  to 
tuberculosis.  Prophylaxis  is  important.  Unfortunately  a  tuber- 
culosis latent  for  nearly  a  lifetime  may  break  out  in  the  presence  of 
diabetes,  as  it  did  in  Case  Xo.  (521),  at  the  age  of  sixty-nine  years,  and 
in  Case  Xo.  344,  in  whose  family  there  had  been  much  tuberculosis, 
though  he  himself  had  never  shown  recognizable  signs  of  it.  Xo 
matter  how  well  the  diabetic  patient  may  appear,  he  remains  a 
vulnerable  individual. 

A  glance  at  Table  17")  shows  that  the  number  of  cases  of  tuber- 
culosis was  far  more  numerous  among  the  early  than  among  the 
late  case  numbers,  another  illustration  of  the  disappearance  of 
tuberculosis  in  the  community  and  probably  an  illustration  of  the 
effects  of  treatment  of  diabetes,  for  I  take  it  that  in  the  last  t'e\v 
years  diabetic  patients  have  not  been  so  debilitated  with  the 
progress  of  the  diabetes.  On  the  other  hand,  an  argument  could 
be  raised  that  recently  diabetic  patients  have  died  prematurely  of 
coma,  whereas,  according  to  the  old  regime,  they  would  have 

1  Montgomery:    Am.  Jour.  Me<l.  Sc-.,  1912,  cxliv,  p.  513. 


TREATMENT  OF  COMPLICATIONS 


405 


lingered  along  and  succumbed  to  some  complication.  This  does 
not,  however,  appear  likely,  because  the  duration  of  life  of  my 
diabetics  compares  favorably  with  that  of  earlier  writers. 

Of  the  34  cases  of  tuberculosis,  0  are  alive,  but  tubercle  bacilli 
are  undoubtedly  present  in  the  sputum  of  Cases  029,  1002,  10S3, 
1 101  and  1221 .  The  duration  of  the  diabetes  in  these  living  patients 
is  considerable.  The  duration  of  the  diabetes  and  tuberculosis  of 
all  my  cases  in  whom  tuberculosis  has  been  demonstrated  is  shown 
in  Table  175. 

TABLE  175. — TUBERCUIOSIS  AND  DIABETES. 

Duration  to  December  1,  1910, 
Age  at  years, 

onset  of 
Diabetes. 


Case 

No. 

443 
629 

10021 
10S3 
11011 
1221 


Case 
No. 

Age  at 
onset  of 
diabetes. 

403  .   . 

55 

404  .   . 

.   .   60 

10  .   . 

.   .   39 

44  .   . 

.   .   42 

2091  .   . 

.   .   27 

453  '   . 
543 

.   .   49 

.   .   62 

633 

.   51 

56  .   . 

.   .   44 

68   .   . 

.   .  42 

751  .   . 

.   .   35 

106  .   . 
134 

.   .   31 

3S 

160  .   . 

.   .  46 

166i     . 

.   .   52 

200  .   . 

.   .   61 

205  .   . 

.   .   51 

206  .   . 
°45 

.   .  41 
30 

324 

52 

344i  .   . 

.   .   40 

353  .   . 

.   .   53 

537   .   . 
761 

.   .   47 
52 

861'  .   . 

.   .   51 

862   .   . 

.   .   26 

SN6   .   . 

.   .   29 

916   .   . 

.   .   58 

54 
.50 
50 


Duration  to  death, 
years. 

Pulmonary 
Diabetes.  tuberculosis.2 

6.1 
10.0  1.0 


Diabetes. 

Pulmonary 
Tuberculosis.2 

6.9 

8.0 

8.2 

2.0 

1.5 

14.0 

0.9 

0.5 

8.1 

8.0 

2.0 

2.3 

12.0 

5.8 
8.6 
4.9 
2.6 
1.8 

7 . 7 
0 . 3 
6.0 
9 . 0 
3.9 
1.6 
4.0 
5.2 
5.0 
7.1 
3.0 
2.0 
S.4 
2.5 
3.5 
3.7 


1.0 

1.0 


0.5 
6.0 
4.0 
1.0 
1.0 
6.0 


Cause  of  death. 
Gangrene. 


Coma. 


>  Tuberculosis. 


1.3 
2.S 
0.3 
1.6 


1  Tubercular  heredity. 

-  The  fixation  of  the  onset  of  tuberculosis  is  of  course  to  a  considerable  degree 
uncertain.  The  statistics  are  so  compiled  that  the  onset  is  earlier  rather  than  later 
than  reported  in  this  table. 


400 


TREATMENT 


Six  of  the  2S  fatal  eases,  or  21  per  cent.,  died  in  coma.  This 
is  far  below  the  percentage  of  deaths  from  coma  in  the  whole  group 
of  diabetics.  It  suggests  that  the  diabetes  decreased  in  severity, 
due  to  the  emaciation  and  lack  of  food  consumed.  Seventeen 
patients  apparently  died  in  the  ordinary  manner  of  an  uncompli- 
cated tuberculous  case.  It  is  interesting  that  of  the  iU  cases  of 
tuberculosis,  my  records  show  that  tuberculosis  was  present,  in  only 
7  instances  in  other  members  of  the  family. 

Contrary  to  my  expectation,  my  records  show  that  frequently 
tuberculosis  occurred  before  the  diabetes.  Proof  is  not  convincing, 
but  my  records  indicate  that  I  felt  this  to  be  true  at  the  time  I 
took  the  history  of  the  individual.  The  explanation  lies  in  the 
fact  that  the  tuberculosis,  though  it  existed  for  a  longer  period,  was 
of  a  latent  or  mild  type. 


Fie.    14.  — Tlll>pr<Miln>i-:    ;uid   diabetes.       The     tcmprrat  lire, 
chart    of    Case    Xo.   '.1 10. 


and    rr>>pirn1ion 


Tuberculosis  comes  on  in  diabetes  even  more  insidiously  than 
u>ual;  more  than  once  I  have  been  surprised  at  discovering  not 
only  its  pre.MMice,  but  the  advance  which  it  has  made.  One  should 
always  be  on  the  watch  for  it,  taking  For  granted  that  it  will  not 
appear  in  an  open  manner,  and  therefore  making  complete  physical 
examinations  of  all  diabetic  case-  several  times  a  year.  Indeed, 
this  is  necessary  for  other  reasons,  for  it  is  a  very  easy  mistake  for 
the  physician  to  be  so  wrapped  up  in  the  treatment  of  the  diabetes 
that  he  neglects  the  general  condition  of  the  patient.  Loss  of  weight 


TREATMENT  OF  COMPLICATIONS  407 

is  attributed  to  the  diabetes,  and  the  absence  of  temperature  throws 
the  physician  off  his  guard.  (Fig.  14.)  I  can  confirm  older  writers 
in  the  rarity  of  hemoptysis.  A  suggestive  family  history  and  an 
.r-ray  examination  help  to  solve  the  diagnosis  of  tuberculosis  in 
diabetes  in  the  exceptional  case  who  has  no  sputum. 

In  Case  No.  G33,  long  under  close  observation  in  the  hospital, 
I  must  confess  that  the  presence  of  tuberculosis  was  first  disclosed 
at  autopsy.  It  was  supposed  by  those  of  us  in  attendance  that  the 
patient's  decline  was  wholly  due  to  severe  diabetes,  ultimately 
culminating  in  pneumonia.  The  postmortem  examination  revealed 
extensive  tuberculosis.  Such  a  mistake  is  not  extraordinary,  for 
shortly  after,  bearing  it  in  mind,  I  saw  a  similar  case  in  the  wards 
of  one  of  the  best  hospitals  in  the  country  where  this  diagnosis  had 
not  been  entertained.  The  tolerance  of  the  patient  in  question  was 
gradually  improving,  but  he  was  losing  weight.  On  the  other  hand, 
an  error  was  made  in  Case  No.  1083  by  neglect  to  observe  the  rise 
in  temperature  upon  two  days  during  his  hospital  stay. 

Tuberculosis,  angina  pectoris,  old  age,  and  diabetes  are  com- 
patible with  a  useful  life  and  a  fair  degree  of  health.  In  Case  Xo. 
029  diabetes  developed  at  the  age  of  seventy-one,  tuberculosis 
became  active  at  seventy-five,  and  angina  pectoris  at  seventy-seven. 
The  patient  came  under  observation  in  July,  1913.  Six  months 
later  tubercle  bacilli  were  found,  though  previous  physical  examina- 
tions had  disclosed  no  lesions.  Undoubtedly  tuberculosis  had 
existed  in  latent  form  since  youth.  Under  the  close  supervision 
of  a  devoted  nurse,  thoroughly  trained  in  diabetes,  the  patient 
attended  to  active  duties,  and  is  now  living  in  comfort  at  the  age 
of  seventy-nine,  an  illustration  of  the  hopefulness  which  one  is 
justified  in  assuming  even  in  the  presence  of  diabetes,  tuberculosis, 
and  angina  pectoris.  My  friend  does  not  enjoy  fasting.  A  summary 
of  his  case  is  given  below: 

TABLE    176. — TUBERCULOSIS,  ANGINA,  OLD  AC;E  AND  DIABETES    COMPATIBLE 
WITH  A  USEFUL  LIFE  AND  FAIK  DEGREE  OF  HEALTH. 

Case  Xo.  629. — Onset  of  diabetes  at  seventy-one  years.  Tuberculosis  became 
active  at  seventy-five  and  angina  pectoris  at  seventy-seven  years  Present  age 
seventy-nine  years. 

Urine. 

Volume,  Nitrogen,       Total  sugar,         Weight, 

Date.  c.c.  Albumin.  grams.  grams.  pounds. 

Sept,  24,  1913  .  .  1450                   0  11.0  58  155 

Feb.      7,  1914  .  .  1175  s.  p.  t,              10.2                    9  15S 

Sept.     3,  1914  .  .  1050  s.  p.  t.                                          15  147 

Jan.     11,  1915  .  .  lf>50  s.  p.  t.               13.0                   10  145 

Nov.  30,  1915  .  .  1200                    0  7  140 

Feb.    26,  1916  .  .  1350                   0  0  13S 

Mar.  10,  1917  .  .  1320  si.  tr.  7.31                   0  1452 

1  Feb.  1,  1917.  2  Note  the  pain  in  weight. 


408  TREATMENT 

Case  No.  8(51,  male  aged  fifty-two  years,  developed  diabetes 
while  traveling  in  Europe  in  1914.  Tuberculosis  superimposed 
itself  upon  the  diabetes,  but  apparently  neither  was  discovered 
until  considerable  progress  had  been  made  in  both.  Through  the 
courtesy  of  Dr.  Lawrason  Brown  I  saw  this  patient,  and  it  is  gratify- 
ing to  record  that  after  less  than  a  day  of  fasting  he  became  sugar- 
free,  and  gradually  acquired  a  tolerance  for  (57  grams  carbohydrate, 
and  hemorrhages  ceased.  Tubercle  bacilli  did  not  disappear  from 
the  sputum,  and  he  subsequently  succumbed  to  tubercular  menin- 
gitis. In  the  intervening  eight  months  the  weight  increased  twenty 
pounds.  How  extensive  an  improvement  can  take  place  in  pul- 
monary tuberculosis  complicated  by  diabetes  is  shown  by  Dr. 
Brown's  letter:  "The  patient  presented  dulness  with  broncho- 
vesicular  breathing  and  increased  vocal  resonance  below  the  fifth 
vertebral  spine  on  the  left  side.  There  were  also  numerous  moder- 
ately coarse  rales.  Over  the  right  side  there  were  moderately 
coarse  and  fine  rales.  Five  months  later  the  lesion  at  the  left 
base  cleared  up  almost  completely.  There  were  a  few  fine  rales  to 
the  third  vertebral  spine,  when  he  left,  on  the  left  side  and  possibly 
below  the  fifth  rib.  The  right  side  still  showed  signs  over  most  of 
the  side." 

The  improvement  in  the  last  two  cases  is  not  exceptional.  Xaunyn 
records  a  case  of  a  physician,  aged  fifty-three  years,  with  diffuse 
pulmonary  tuberculosis,  and  also  a  small  ulcer  on  the  left  vocal 
cord,  in  whose  urine  was  found  4  per  cent,  of  sugar.  Careful  treat- 
ment of  the  diabetes  and  the  tuberculosis  gradually  brought  about 
a  gain,  although  some  months  after  the'  beginning  of  the  treatment 
there  was  slight  hemoptysis,  with  tubercle  bacilli  present.  The 
condition,  however,  kept  improving,  and  sixteen  years  later  both 
diseases  were  apparently  arrested. 

The  advent  of  diabetes  upon  tuberculosis  is  seldom  reported,  as 
observed  in  cases  of  tuberculosis  treated  in  sanatoria.  Mont- 
gomery1 found  that  of  ol,8o4  cases  of  tuberculosis  treated  in  sana- 
toria there  were  101  (about  \  of  1  per  cent.)  cases  of  glycosuria  and 
ol  (about  I,  of  1  per  cent.)  cases  of  diabetes,  and  he  states  that 
practically  not  a  case  of  diabetes  following  tuberculosis  has  occurred 
at  the  Phipps  Institute,  in  the  sanatoria  or  under  the  care  of 
physicians  with  whom  he  is  acquainted. 

Case  No.  44o,  a  woman,  aged  fifty-five  years,  first  seen  on  Sep- 
tember 120,  1011,  gave  a  history  of  congestion  of  the  lungs  at  the 
age  of  twelve,  hemoptysis  at  sixteen,  and  again  to  a  marked  degree 
at  the  age  of  twenty-four.  Tuberculosis  was  confirmed  by  Drs. 
Flint  and  Loomis,  of  Xew  York.  Tubercle  bacilli  were  never  found, 
but  the  evidence  of  tuberculosis  was  undoubted.  An  .r-ray  examina- 

1  Montgomery:     Amer.  Jour.  Mod.  Sc.,  11)1-',  clxiv,  p.  643. 


TREATMENT  OF  COMPLICATIONS  409 

tion  on  September  21,  1911,  showed  general  peribronchitis  with 
numerous  broken-down  glands  with  healed  borders,  increased 
density  and  mottling  with  an  appearance  of  healing  at  the  right 
apex,  small  areas  of  calcification,  slight  emphysema.  The  patient 
was  sugar-free  in  September,  1911,  and  is  alive  today. 

The  reason  for  the  advent  of  the  diabetes  in  these  two  instances 
may  be  explained  by  the  latency  of  the  tuberculosis,  and  the 
explanation  for  the  rarity  of  diabetes  in  tubercular  sanatoria  is 
shown  by  the  course  of  the  case  described  in  the  next  paragraph. 

Diabetes,  even  of  the  severest  grade,  may  practically  disappear 
when  tuberculosis  intervenes  and  reaches  an  advanced  stage. 
Many  writers  have  observed  such  instances.  Case  No.  344,  cited 
hitherto  as  having  an  extremely  severe  type  of  diabetes,  developed 
tuberculosis  after  eight  years.  Eventually  the  acidosis,  which 
had  amounted  to  the  most  extreme  grade  which  I  have  met  outside 
of  coma,  completely  disappeared,  and  a  minus  carbohydrate  bal- 
ance of  40  grams,  which  had  existed  for  months,  changed  to  a 
positive  carbohydrate  balance  of  60  grams.  The  complete  record 
of  the  case  is  given  below.  (Table  177.) 

The  disappearance  of  the  acidosis  is  explained  by  the  development 
of  a  positive  carbohydrate  balance.  The  explanation  of  the  body's 
regaining  power  to  utilize  carbohydrates  was  difficult  until  I  showed 
the  records  of  the  case  to  Dr.  Allen  and  told  him  that  if  he 
could  explain  the  improvement  of  the  diabetes  coincident  with  the 
development  of  tuberculosis,  a  key  to  a  valuable  method  of 
treatment  of  diabetes  would  be  found.  A  few  days  later  he  said 
to  me  that  he  believed  he  could  duplicate  the  case  with  his  depan- 
creatized  dogs.  How  well  he  succeeded  is  known  today  by  his 
experimental  work  upon  animals,  which  showed  that  fasting  and 
loss  of  weight  will  improve  the  tolerance  of  even  the  severest  diabetic 
patients. 

Older  writers  laid  emphasis  upon  the  rapid  extension  of  the  tuber- 
culosis in  diabetes  after  it  first  appeared,  and  for  this  reason  gave 
an  especially  unfavorable  prognosis.  Examples  of  this  character 
are  only  too  many,  but  while  they  are  not  encouraging  from  the 
therapeutic  point  of  view,  they  should  not  be  considered  too  dis- 
couraging. It  is  possible,  indeed  probable,  that  many  of  these 
cases  had  poor  treatment  not  only  for  the  diabetes  but  for  the 
tuberculosis  as  well.  The  duration  of  the  tuberculosis  as  well  as 
of  the  diabetes  in  my  cases  absolutely  controverts  this  former 
pessimistic  view.  Of  the  24  cases  in  which  the  duration  of  the 
tuberculosis  is  recorded,  in  only  3  instances  lias  the  patient  died 
during  the  first  year  of  the  tuberculosis.  In  one  instance  only  did 
the  diabetes  last  for  less  than  one  year.  These  facts  are  shown  in 
Table  175. 


410 


TREATMENT 


S~ 
n 


c       5       £5 


.£  ?  £  2,          -i—  ^S—  2  *^  5'6  ?£. 


-f         -r  -r-ff 


-H  -«    « 

OO     .OO 


TREATMENT  OF  COMPLICATIONS 


411 


O  COO  CO 


CO  CO         CO  CO         CO 


M      I  0)  01  01  01 


+      + 
+     + 

+     + 


oi  a          ot 


412 


TREATMENT 


I     II         +  I  I    I    I  I  II        III     I  I  +  I   '  I  I  I 


TREATMENT  OF  COMPLICATIONS 


413 


3.  Arteriosclerosis. — Bright's  Disease. — Arteriosclerosis  is  of  com- 
mon occurrence  in  protracted  cases  of  diabetes.  It  is  of  the  senile 
type.  It  seldom  occurs  even  in  the  severest  cases  of  diabetes  in 
youth  or  middle-age — a  strong  argument  against  diabetes  being  a 
direct  causative  factor  of  arteriosclerosis. 

A  study  of  the  blood-pressure  of  a  series  of  my  diabetic  cases  favors 
the  view  that  the  presence  of  sugar  and  acid  in  the  urine  does  not 
injure  the  arteries  or  kidneys.  Thus,  only  19  per  cent,  of  the  cases 
occurring  between  the  ages  of  twenty-one  and  fifty  exhibited  a 
blood-pressure  of  over  150.  What  is  still  more  confirmatory  of 
this  point  is  the  fact  that  07  per  cent,  of  the  patients  of  fifty-one 
years  of  age  and  over  showed  a  blood-pressure  between  100  and 
150.  The  blood-pressures  of  diabetic  patients  between  the  ages 
of  twenty-one  and  fifty,  and  fifty-one  and  over  are  shown  in 
Table  178: 

TABLE  178. — THE  BLOOD-PRESSURE  IN  DIABETES. 


100-125          120-150          151-17; 

No.  of  cases  21-50  years  of  age          174  191  50 

No.  of  cases  over  50  years  of  a^e       172  283  129 


176-200     Above  200 
19  8 

62  29 


The  blood-pressure  was  determined  with  the  Riva  Rocci  apparatus 
and  a  Janeway  cuff  14  cm.  wide.  Occasionly  the  Tycos  apparatus 
was  used,  but  its  reading  was  frequently  checked  up  with  the 
mercury  manometer.  The  blood-pressure  was  taken  with  the 
patient  lying  down  except  in  the  rarest  instances. 

TABLE  179. — THE  AVERAGE  BLOOD-PRESSURE  OF  NORMAL  AXD  DIABETIC 

INDIVIDUALS. 


ARCS. 
15-20    .      .      . 
21-25     .      .      . 
2(5-30    .      .      . 
31-35 

Normals, 
Fisher. 

281 
.      .         785 
.      .         791 
689 

Diabetics 
Joslin. 

38 
33 
56 
39 

36-40    .      .      . 
41-45    .      .      . 
40-50    .      .      . 
51-55    .      .      . 
56-60     .      .      . 
Over  60       .      . 

.      .      2,111 
.      .      6,740 
.      .      4,471 
.      .      2,371 
.      .      1,100 

64 
75 
116 
127 
103 
163 

Average  blood-pressure, 

mm. 

Hg, 

Normals, 

Diabetics, 

Fisher. 

Joslin. 

120 

121 

123 

122 

124 

121 

124 

120 

127 

125 

129 

139 

131 

143 

1)52 

154 

135 

154 

1561 

19,339 


814 


127 


139 


In  Table  179  the  blood-pressures  of  normals  and  diabetics  are 
compared.  Fisher-  gives  the  blood-pressure  for  19,339  accepted 
candidates  for  life  insurance,  and  additional  information  is  added 

'  Not  included  in  average. 

-  Fisher:  Jour.  Am.  Mod.  Assn.,  1914,  xliii,  p.  1752. 


414 


THE  AT  ME  XT 


o     .     .10 


TREATMENT  OF  COMPLICATIONS 


415 


416  TREATMENT 

in  a  subsequent  letter  quoted  by  T.  C.  Janeway:  "Dr.  Fisher  has 
written  me  personally  that  since  this  publication  he  has  been  in- 
formed of  a  record  of  9000  readings  by  another  company  which 
did  not  vary  1  mm.  in  the  average  of  any  age  from  those  he  has 
tabulated — making  an  average  standard -based  upon  the  observation 
of  over  2S,()()()  healthy  adults."  The  blood-pressures  of  S14  of  my 
diabetic  patients  are  placed  alongside  Fisher's  table.  The  striking 
similarity  of  the  blood-pressures  in  Fisher's  and  my  tables  up  to  the 
age  of  forty  years  makes  the  immediate  divergence  of  the  two  groups 
in  subsequent  decades  noteworthy  and  demands  an  explanation. 

Janeway's  conclusions1  coincide  with  my  data.  He  writes: 
.  .  .  it  is  clear  from  my  own  observations  and  those  of 
Elliott-  that  diabetes  itself  is  without  influence  on  the  arterial 
pressure.  Hypertension  is  therefore  presumably  an  expression  of 
the  well-known  tendency  of  diabetics  of  suitable  age  to  develop 
arterial  disease;  or  possibly  in  some  cases  arterial  disease  is  the 
cause  of  the  lesions  responsible  for  the  diabetes." 

Cadbury,3  at  the  Peter  Bent  Hrigham  Hospital,  found  in  a  study 
of  ))()")  patients  that  a  systolic  blood-pressure  of  100  mm.  mercury 
or  more  was  accompanied  by  definite  signs  of  chronic  nephritis  in 
73  per  cent,  of  the  individuals  examined. 

Low  blood-pressures  are  frequently  encountered  with  diabetic 
patients.  My  records  are  not  full  upon  this  point,  but  I  shall  pay 
more  attention  to  this  question  in  the  future.  In  Table  LSI  arc 
grouped  10  cases  showing  such  low  blood-pressures.  Cases  with 
inanition  stand  out  prominently  among  the  group  of  those  in  which 
the  blood  tension  was  low.  It  was  partly  for  this  reason  that  in  these 
cases  massage  and  exercise  have  been  considered  important. 

TABLE  181. — -CASES  OF  DIABETICS  WITH  BLOOD-PRESSURE  OF  100  MM.  HG 

OR  BELOW. 


Case  Xos. 


Number  of  cases          220231 

Another  source  of  information  upon  the  influence  of  diabetes  on 
blood-pressure  can  be  found  by  comparing  the  blood-pressure  of  a 
series  of  diabetics  during  subsequent  stages  of  the  disease.  For  this 
purpose  Table  ISO  has  been  arranged: 

'  June-way:  Johns  II. i,, kins  Hosp.  Hull..  I'M'),  xxvi.  p.  :ill. 
*  Elliott  :'  .lour.  Am.  Mr<l.  Assn..  1907.  xlix,  p.  27. 
3Cudhuiy:  Arch.  Int.  Mud.,  1'JIU,  xviii,  p,  317. 


15-20. 

121  1'."). 

20-30. 

:u  3o. 

33-40. 

51-55. 

1130 

1143 

100.") 

1085 

!()()() 

1101 

1227 

1102 

10LS 

1215 

1073 

1159 

1155 

1196 

12:52 

12.59 

TREATMENT  OF  COMPLICATIONS  417 

A  detailed  study  of  the  2'.}  cases  in  which  the  blood-pressure  fell 
showed  14  in  which  this  was  associated  with  disappearance  of  sugar. 
In  my  opinion  the  restricted  diet  as  a  whole  had  much  to  do 
with  this,  but  the  improvement  in  the  diabetes  was  undoubtedly 
important. 

Case  No.  727,  with  onset  of  diabetes  at  the  age  of  fifty-one  years, 
showed  when  she  was  first  seen  at  the  age  of  fifty-five,  May  14, 
1914,  7.0  per  cent,  of  sugar.  The  systolic  blood-pressure  was  220 
mm.  (Riva  Kocci).  The  changes  in  the  urine  and  in  the  blood- 
pressure  during  the  course  of  treatment  are  given  iu  Table  182. 

TABLE  182. — CASE  Xo.  727.     CHANGES  IN  BLOOD-PRESSURE  DURING 
TREATMENT  FOR  DIABETES. 


Date. 
1914 

May  14  .      .      .      . 
17  .      .      .      . 

25 

Total   sugar, 
grams. 

.        (7.6<~c) 

.      .     78 
23 

Carbohydrate 
balance. 

110 
80 

Weight, 
pounds. 

114 
113 

Blood- 
pressure. 

220 

June    4  . 
Aug.  13  .      .      .      . 
Nov.  17  .      .      .      . 
Dec    31 

.      .       0 
.      .       0 
.      .       0 

o 

10 
45 

70 

llli 

122\ 
12GJ 
128 

180 
170 
160 

1915 
Mar.  29  .      .      .      . 
July  22  .      .      .      . 
Nov.    2  .      .      .      . 

0 
.      .       0 
.      .       0 

70 
70 

127| 
125 

Attack 

160 

150 

of  gall-stones. 

1916 
Feb.  23  .      .      .      . 
1917 
Mar.  1     ... 

.      .       0 

•      •      •     1% 

70 

123 
123 

180 
160 

Case  Xo.  <(),  with  development  of  gangrene,  dieted  rigidly,  lost 
weight,  became  sugar-free,  and  the  blood-pressure  fell.  He  recovered 
without  operation.  Case  Xo.  872  is  described  on  page  418. 

It  is  possible  that  in  the  past  the  excessive  feeding  of  diabetic 
patients  and  particularly  the  excessive  quantity  of  protein  may  have 
predisposed  the  diabetic  patient  of  advancing  years  to  an  earlier 
appearance  of  vascular  changes.  It  will  be  most  interesting  to 
note  whether  diabetic  patients  treated  with  the  modern  restricted 
diet  are  prone  to  such  a  condition. 

Arteriosclerosis,  on  the  other  hand,  may  play  an  important  role 
in  the  production  of  diabetes.  Many  pathologists  have  pointed  out 
the  presence  of  arteriosclerotic  changes  in  the  vessels  of  the  pancreas, 
liver  and  brain,  and  have  called  attention  to  resulting  degeneration 
of  these  organs  which  might  lead  to  diabetes.  This  view  appears 
most  reasonable.  According  to  Xaunyn's  conception  of  diabetes, 
those  individuals  with  an  inherent  though  mild  tendency  to  diabetes 
would  be  prone  to  develop  the  disease  when  degenerative  bodily 
changes  begin  to  appear. 
27 


4  IS  TREATMENT 

An  illustrative  case  is  Xo.  ()2(),  who,  after  several  years  of  cir- 
culatory symptoms  with  annoying  angina  pectoris,  developed 
diabetes  at  the  age  of  seventy-one,  and  also  Case  No.  S72  who  had 
a  blood-pressure  of  2.">0  at  the  age  of  sixty-five  without  quantitatable 
sugar  in  the  urine,  but  in  whose  urine  three  years  later  .1.12  per  cent, 
of  sugar  was  found.  After  treatment  of  the  diabetes  sugar  dis- 
appeared, and  the  blood-pressure  fell  in  succeeding  years  to  230, 
220  and  210.  Coineidentally  there  has  been  marked  amelioration 
of  the  anginal  pains,  and  the  patient  says  he  feels  better  than  for 
years.  The  improvement  may  be  due  to  the  gradual  loss  of  weight 
which  occurred  following  the  onset  of  the  diabetes. 

Few  cases  of  arteriosclerosis  in  diabetic  patients  appear  to  result 
from  syphilis.  Syphilis  may  be  far  more  common  among  diabetic 
patients  than  has  hitherto  been  proven,  and  I  suspect  exists  far  more 
frequently  among  my  own  cases  of  diabetes  than  my  records  show: 
there  were  1(1  case's  with  a  history  of  syphilis  among  a  total  of  1187 
patients.  The  routine  introduction  of  the  Wassermann  test  will 
furnish  much  valuable  information  upon  this  point.  Wassermann 
tests  have  been  performed  upon  107  cases  of  my  series.  These 
were  selected  partly  by  routine,  but  special  pains  have  been  taken 
to  have  the  test  made  in  suspicious  cases.  Yet  of  the  total  number 
of  107  patients  whose  blood  was  tested,  only  0  gave  a  positive 
result.  This  is  confirmatory  of  clinical  and  pathological  observa- 
tion that  the'  type  of  arteriosclerosis  which  one  sees  in  diabetes  is 
not  that  which  is  usually  attributed  to  syphilis. 

The  symptoms  of  which  diabetic  patients  suffering  from  arterio- 
sclerosis complain  are  chiefly  related  to  the  lower  extremities  and 
the  heart  but  less  commonly  to  the  brain,  characteristic  symptoms 
of  senile  rather  than  syphilitic  arteriosclerosis.  Pains  and  numb- 
ness of  the  legs  and  cold  feet  are  very  common.  Intermittent 
claudication  occurred  in  Case  Xo.  8  one  year  before  a  cerebral 
hemorrhage.  The  whole  train  of  symptoms  leading  up  to  gangrene 
often  extends  through  a  period  of  months,  and  these  patients 
sutler  more  than  those  with  actual  gangrene.  The  cardiac  symp- 
toms are  more  of  the  order  of  angina  pectoris  than  of  cardiac 
incompetency.  Indeed,  angina  pectoris  is  fairly  common,  though 
my  records  show  only  7  cases  in  which  there  was  sudden  death 
from  this  cause.  Cases  Xos.  11,  lid,  2Sf),  :5.V>,  -Jlo,  -11M  and  7.")!). 
Case  Xo.  11,  whose  brother  died  of  diabetes  at  fifty-two  years, 
developed  diabetes  at  fifty-eight  and  came  under  my  observation 
six  years  later  when  I  was  called  to  see  her  during  a  midnight  attack 
of  angina  pectoris.  Some  weeks  later  she  went  through  a  course 
of  restricted  diet,  became  temporarily  sugar-free,  but  ultimately 
sugar  returned.  After  three  months  death  occurred  in  a  second 
attack.  At  the  time  1  was  self  condemnatory  and  inclined  to  attrib- 


T 'RE ATM  EXT  OF  COMPLICATIONS  419 

ute  the  final  attack  of  angina  pectoris  to  the  change  in  diet,  but  in  the 
subsequent  fourteen  years  this  experience  has  not  been  duplicated. 

Cardiac  incompetency  is  rare.  Case  Xo.  354,  with  onset  of 
diabetes  at  fifty,  died  with  such  symptoms  at  the  age  of  seventy, 
but  for  the  preceding  one  or  two  years  the  sugar  in  the  urine  had 
been  replaced  by  albumin.  Case  No.  234,  who  developed  mild 
diabetes  in  addition  to  his  obesity  at  the  age  of  seventy-seven, 
died  with  symptoms  of  heart  failure.  The  cardiac  asthma  often 
referred  to  in  the  older  diabetic  literature  has  not  been  recognized 
by  me.  1  can  recall  no  case  of  diabetes  under  fifty  years  of  age  in 
which  the  patient  complained  of  shortness  of  breath  or  presented 
the  signs  of  an  incompetent  heart  due  to  uncomplicated  valvular 
disease.  I  know  of  but  one  case  of  rheumatic  fever  in  a  diabetic 
patient.  Case  Xo.  694,  a  mild  diabetic,  had  a  slight  attack  in  the 
spring  of  1917. 

Bri ght's  Disease. — Albuminuria  is  frequently  observed  in  the 
urines  of  diabetic  patients,  but  actual  Bright's  disease,  like  arterio- 
sclerosis, is  practically  unknown  except  in  cases  past  fifty  years  of 
age.  The  relation  between  Bright's  disease  and  diabetes  is  shown 
by  a  study  of  the  blood-pressures  of  diabetic  cases  during  successive 
years.  (Table  ISO.)  The  course  of  the  disease  in  a  series  of  my 
patients  who  presented  undoubted  evidence  of  Bright's  disease  is 
indicated  in  Table  1S3.  It  is  seldom  that  one  sees  death  from 
uremia.  Confusion  rarely  exists  between  uremic  and  diabetic  coma 
except  in  cases  of  pregnancy.  In  other  words,  the  renal  compli- 
cations of  diabetes  have  been  unimportant  in  the  past,  but  with  the 
prolongation  of  life  which  modern  treatment  is  bringing  about  they 
will  deserve  attention.  Cases  Xos.  20,  57,  211,  233,  287,  354,  410, 
421,  425,  470,  725,  S59,  S72,  1030  and  10SG  were  cases  in  which 
the  condition  of  the  kidneys  was  quite  as  important  as  the  diabetes. 

Cerebral  arteriosclerosis  (including  under  this  term  such  diag- 
noses as  cerebral  hemorrhage,  apoplexy,  hemiplegia,  or  paralysis) 
was  responsible  for  the  death  of  20  cases. 

Treatment, — The  treatment  of  diabetes  in  the  presence  of  arterio- 
sclerosis, whether  general  or  primarily  localized  in  the  kidney,  must 
not  be  undertaken  lightly.  Years  ago  this  was  impressed  upon  me 
by  Case  Xo.  347,  who  became  sugar-free  under  the  old  regimen  of 
restricted  carbohydrate  and  increased  fat-protein  diet.  Soon  after 
discharge  from  the  hospital,  however,  acidosis  increased,  and  coin- 
cidently  with  this  a  latent  nephritis  broke  out,  and  death  in  coma 
followed.  The  greater  sensitiveness  of  patients  with  diseased 
kidneys  to  acidosis  was  pointed  out  by  Goodall  and  Joslin.1 

It  should  also  be  remembered  that  an  acidosis  develops  in  the 

1  Goodall  and  Jo.slin:  Boston  Mod.  and  Rurg.  Jour.,  190S,  clviii,  p.  799. 


420 


TREATMENT 


course  of  Bright's  disease  quite  independently  of  the  acidosis  which 
occurs  in  diabetes.     This  was  noted  by  Frothingham.1 

TABLE  183. — THE  COURSE  OF  A  SERIES  OF  CASES  OF  DIABETES 
ASSOCIATED  WITH  BRIGHT'S  DISEASE. 


Duratio  i  in 

Blood 

years  fr  >m 

Case 

No. 

Age  at 
onset  of 

Albumin  in  urine. 

sugar,         Klood- 
per         pressure. 

|  onset    >f 
diabetes   mtil 

Cause  of 
death. 

diabetes 

cent. 

death    >r 

Dee.  1,  1910. 

16 

66 

Slightest  possible  trace 

Uremia. 

26 

51 

Very  slight  trace 

3 

Bright  's. 

57 

57 

Very    slight    trace    to 

s 

Hemiplegia. 

slight  trace 

85 

58 

0.3  to  0.7  per  cent. 

12 

Bright'a. 

211 

45 

0.05  to  0.1  per  cent. 

3 

Bright's. 

233 

54 

0.1  to  0.9  per  cent. 

150  -220 

15 

Coma. 

287 

57 

Slightest  possible  trace 

190 

5 

Hemiplegia. 

to  very  slight  trace 

334 

GO 

Very    slight    trace    to 

20 

Uremia. 

slight  trace 

337 

40 

Slight,  trace  to  trace 

100 

15 

Uremia. 

35  \ 

50 

0.15  to  0.2  per  cent. 

ISO 

11 

Bright.  's. 

3SS 

69 

Slight  trace 

170 

3 

Bright's. 

416 

54 

Slightest  possible  trace 

0.23   ,   ISO  -200 

9 

Hright's. 

to  slight  trace 

421 

53 

0.15  to  0.2  per  cent. 

150    ISO 

9 

(  'ardiac. 

425 

47 

Slightest  possible  trace 

180 

8 

(  'ardiac. 

to  very  slight  trace 

725 

52 

Very    slight    trace    to 

190 

1 

Hemiplegia. 

slight   trace 

75S 

54 

Slightest  possible  trace 

215 

2 

Coma. 

to  trace 

859 

52 

Slight    trace    (0.1    per 

140    1S5 

15 

Cerebral 

cent.) 

hemorrhage. 

1015 

47 

Slight  trace 

1..37             SO 

Annria. 

703 

54 

Trace 

0.1S           1S5 

S 

Alive. 

S72 

63 

Very  slight  trace 

200-250 

3 

" 

910 

47 

0.3  per  cent, 

0.27          175 

20 

" 

070 

33 

0.05  to  0.1  per  cent. 

0.24          120 

17 

" 

1030 

55 

0.05  to  0.1  per  cent. 

0.22          150 

12 

" 

10SG 

07 

0.05  to  0.1  per  cent. 

0.15          215 

3 

" 

1157 

59 

Very  slight  trace 

0.23           190 

(i 

That  marked  changes  in  the  diet  seriously  affect  the  circulation 
I  am  also  led  to  believe  by  Case  Xo.  859,  who,  in  the  course  of 
fasting  treatment,  developed  symptoms  which  indicated  marked 
disturbance  of  the  cerebral  circulation,  though  no  actual  paralysis 
developed.  These  examples  show  how  careful  one  should  be  in 
attempting  to  better  the  condition  of  arteriosclerotic  patients  who 
have  diabetes.  They  furthermore  show  why  the  older  generation 


rrothiaghain:  Arch.  lut.  Mod.,  1916,  xviii,  p.  717. 


TREATMENT  OF  COMPLICATIONS  421 

of  doctors  hesitated,  and  at  that  period  with  good  reason,  to  alter 
the  diet  of  such  of  their  elderly  patients  who  were  leading  tolerably 
comfortable  lives.  Today  the  dangers  attending  the  beginning  of 
treatment  of  such  individuals  are  gradually  lessening,  and  my 
ideas  of  the  treatment  of  diabetes  in  conjunction  with  arterio- 
sclerosis have  changed  much  in  the  last  year  and  a  half  since  Dr. 
Ilornor  and  I  have  studied  the  cases  with  a  duration  of  fifteen  or 
more  years.  At  present,  after  much  reflection  and  conversations 
with  members  of  the  families  of  these  patients,  I  am  convinced  that 
treatment  of  diabetes  can  take  place  without  detriment,  and  that, 
on  the  contrary,  it  may  be  of  distinct  help  (see  p.  468).  This  change 
in  view-point  is  due  to  the  ability  to  prevent  the  appearance  of  acid 
poisoning  in  these  individuals  while  they  are  becoming  sugar-free 
and  the  avoidance  of  changes  in  the  water  content  of  the  body, 
which  takes  place  so  commonly  when  alkalis  are  given. 

Acid  poisoning  may  be  avoided  in  the  treatment  of  arteriosclerotic 
diabetics  by  the  elimination  of  fat  from  the  diet.  This  reduction 
in  the  total  caloric  value  of  the  food  may  be  sufficient  to  render 
the  urine  free  from  sugar,  but  should  this  not  be  the  case  at  once, 
no  change  in  the  diet  need  be  made  for  the  following  two  or  three 
days  unless  the  total  quantity  of  sugar  fails  to  decrease.  During 
this  interval  the  quantity  of  carbohydrate  in  the  diet  should  be 
kept  the  same  as  upon  the  day  before  treatment  was  commenced, 
or  if  this  was  as  much  as  100  grams  or  over,  dropped  to  100  grams 
and  then  reduced  20  grams  daily.  The  quantity  of  protein  should 
be  limited  to  1  gram  per  kilo.  If  the  sugar  is  not  steadily  decreasing, 
after  three  days  the  protein  should  be  omitted  and  the  carbohydrate 
halved,  and  if  necessary,  halved  again  the  second  day.  It  will  not 
then  exceed  10  grams,  and  there  would  be  no  danger  in  fasting  the 
patient  for  twenty-four  hours  if  the  urine  was  not  sugar-free.  So 
soon  as  the  urine  is  sugar-free  the  quantity  of  carbohydrate  may 
gradually  be  increased  until  sugar  returns  or  the  carbohydrate 
amounts  to  30  grams.  Protein  should  then  be  added,  and  the  plan 
of  diet  followed  as  in  other  cases. 

Change  in  the  water  content  in  the  body  is  avoided  during  the 
alteration  of  the  diet  by  watching  the  patient's  weight  and  increasing 
or  decreasing  the  fluids  and  salt  ingested.  It  is  particularly  neces- 
sary during  a  fast  to  give  the  patient  liquids  containing  salt. 
Case  Xo.  941  informed  me  that  he  lost  13  pounds  during 
four  days  of  fasting  in  one  of  the  best  clinics,  but  inquiry  showed 
that  during  these  days  he  drank  only  pure  water.  Had  he  taken 
broths  freely,  or  a  mineral  water,  most  probably  weight  would  not 
have  been  lost,  because  the  fluid  content  of  the  body  would  have 
been  increased.  A  loss  of  13  pounds  in  four  days  could  obviously 
only  be  accounted  for  by  fluid  loss,  This  is  plain,  because  1  kilogram 


422  TREATMENT 

('2:1  pounds)  of  fat  would  furnish  0000  calories,  and  undoubtedly 
the  patient  did  not  use  up  six  times  this  amount  of  nourishment 
in  the  four  days. 

It  should  he  remembered  that  there  is  no  need  for  hurry  in  the 
treatment  of  diabetes  in  the  presence  of  arteriosclerosis,  because 
the  diabetes  has  probably  existed  for  a  long  time,  and  under  treat- 
ment it  is  hoped  that  the  patient  will  continue  to  live  for  many 
years  to  come.  Therefore  the  few  days  spent  in  preliminary  treat- 
ment are  no  deterrent  to  its  employment. 

The  improvement  in  the  condition  of  patients  showing  Bright's 
disease  and  diabetes  combined  is  often  striking.  So  frequently 
is  this  circumstance  noted  that  it  cannot  be  lightly  passed  over. 
Presumably  the  restricted  diet  and  the  low  protein  in  the  modern 
diabetic  treatment  conduce  to  this  result,  quite  apart  from  the  fact 
that  the  Bright's  disease  has  previously  been  made  worse  by  the 
diabetes.  In  the  presence  of  Bright's  disease  the  quantity  of  protein 
in  the  diet  should  be  kept  as  low  as  1  gram  per  kilogram  body  weight, 
and  frequently  quite  under  this  amount.  Repeatedly  patients  with 
Bright's  disease  acquire  an  increased  tolerance  for  carbohydrate  as 
the  Bright's  disease  increases  in  intensity.  This  often  is  quite  a 
comfort  to  the  patient,  and  the  physician  should  be  always  on  the 
watch  for  it,  so  as  to  give  these  individuals  the  benefit  of  the 
freedom  of  diet  of  which  they  have  so  long  been  deprived.  The 
possibility  of  renal  "block"  should  be  borne  in  mind. 

The  appearance  of  acid  poisoning  with  change  to  a  protein-fat 
diet  is  illustrated  by  Case  Xo.  75*),  Table  217,  p.  479,  with  onset 
of  diabetes  at  the  age  of  forty,  who  later  developed  angina 
pectoris  and  came  under  my  observation  August  2S,  1914,  at 
the  age  of  fifty-four  years.  After  moderate  restriction  of  diet 
at  that  time  the  patient  was  temporarily  made  sugar-free.  The 
diet  was  not.  followed,  sugar  returned,  and  the  patient  was  weak, 
uncomfortable,  able  to  walk  but  short  distances.  Prior  to  returning 
for  treatment  in  1915,  through  the  advice  of  a  niece,  who  also  had 
had  diabetes,  she  placed  herself  upon  a  fat-protein  diet  in  anticipa- 
tion of  her  visit,  to  me,  with  the  result  that  marked  acidosis  appeared, 
as  shown  by  the  urine  of  September  27,  1915.  During  the  following 
days  fat  was  excluded  from  the  diet,  but  carbohydrate  and  protein 
allowed.  The  sugar  decreased,  but  far  more  important,  the  acidosis 
promptly  disappeared.  On  October  1  she  entered  the  New  England 
Deaconess  Hospital  and  quickly  became  sugar-free  when  carbo- 
hydrate was  gradually  reduced.  At  the  end  of  fifteen  days  the 
patient  left  the  hospital  with  a  tolerance  for  carbohydrate  of  4S 
grains,  protein  05  grains,  fat  52  grams,  and  an  ability  to  walk  three 
and  a  half  miles  without  bringing  on  any  symptoms  of  angina 
pectoris.  Nine  months  later  she  died  in  an  attack.  Had  this  patient 


TREATMENT  OF  COMPLICATIONS  423 

been  treated  in  the  same  way  as  Case  Xo.  347  (see  p.  170),  serious 
or  even  fatal  complications  might  have  ensued. 

The  surprising  improvements  which  occur  in  the  circulatory 
symptoms  of  these  patients  quite  likely  may  be  due  to  the  decrease 
in  weight  which  ensues  upon  the  restricted  diet.  Thus  along  with 
the  treatment  of  diabetes  very  desirable  treatment  of  the  arterio- 
sclerosis is  accomplished. 

The  extent  of  the  influence  of  the  kidney  has  been  determined  in 
several  cases  by  the  phenolphthalein  test.  The  excretion  of  the 
drug,  however,  has  varied  to  a  considerable  extent,  not  only  in 
different  cases  but  in  the  same  patient.  This  is  brought  out  especi- 
ally in  Case  Xo.  1233,  described  on  page  385.  Undoubtedly  the 
retention  of  fluid,  as  shown  by  moderate  edema,  accounts  for  part 
of  this  variation,  but  very  likely  not  for  all  of  it.  At  present  my 
assistant,  Richard  Ohler,  is  making  a  special  study  of  the  renal 
conditions  of  various  groups  of  my  cases,  and  it  seems  best  to  defer 
further  statements  until  more  data  have  been  collected  and  these 
have  been  carefully  analyzed. 

4.  Gangrene. — Gangrene  has  occurred  in  37  cases,  or  3  per  cent, 
of  my  series — in  28  males  and  9  females.  Two  per  cent,  of  my 
living  cases  of  diabetes  have  had  gangrene.  It  was  present  in  (>  per 
cent,  of  the  fatal  cases. 

This  gives  a  wrong  impression,  however,  of  the  frequency  of 
gangrene,  and  a  much  better  idea  of  its  importance  in  diabetes  is 
seen  by  a  study  of  Table  184,  in  which  the  frequency  of  gangrene 
according  to  the  age  of  the  patient  is  recorded.  The  youngest 
patient  save  one,  who  developed  gangrene  at  twenty-eight  years, 
was  fifty  and  the  age  of  the  oldest  seventy-four  years.  In  Boston 
during  the  years  1895  to  1913  Morrison'  found  that  gangrene 
appeared  in  178,  or  23  per  cent.,  of  775  fatal  cases  of  diabetes. 

There  was  no  occurrence  among  my  cases  of  gangrene  in  an 
upper  extremity.  In  two  instances  gangrene  occurred  in  both 
lower  extremities,  and  amputation  of  each  leg  was  required,  and  the 
remaining  leg  of  Case  Xo.  895  is  now  infected,  subsequent  to  recovery 
from  pneumonia.  Case  X'o.  343,  with  onset  at  fifty-eight  years  of 
age,  lost  one  leg  from  gangrene  when  sixty-two  years  of  age,  and 
the  other  leg  two  years  later,  death  resulting  at  the  age  of  sixty- 
five.  Case  X"o.  355  died  of  angina  pectoris  four  years  and  eight  • 
months  after  the  second  operation,  sugar  remaining  absent  from 
the  urine  during  nearly  the  whole  of  this  period.  Case  Xo.  58  is  also 
remarkable  for  the  long  duration  of  the  disease  following  amputation 
of  the  leg.  He  was  seen  by  me  while  undergoing  treatment  for  the 
morphin  habit  five  years  subsequent  to  the  onset  of  diabetes.  Gan- 

1  Morrison:  Loe.  cit.,  p.  34. 


424  TREATMENT 

grene  occurred,  and  a  leg  was  removed,  but  the  patient  lived  eight 
years  after  the  operation. 

The  age  at  onset  of  the  gangrene  is  good  proof  that  the  disease  is 
not  due  to  the  diabetes  alone,  for  only  S  of  .'57  cases  occurred  under 
the  age  of  fifty.  Gangrene  may  come  in  the  diabetic  with  advancing 
years,  as  is  proven  by  the  statistics  recorded  in  Table  184: 

TABLE  184. — (!ANGKE.\E  ix  DIABETES. 


A  ire  at  onset 

Total  rases  of 

Cases  of  cantrrene. 

of  diabetes. 

diabetes. 

No.  of  eases.             I'er  eent. 

Under  30  years    . 

,       .       .       .      201 

1                   0.4 

3  !-")()     " 

434 

7                   2.0 

51-00              .      .      . 

.      .      .      2of> 

9                   3.0 

01-70              .      .      . 

.      .      .      12!) 

13             10.0 

71-SO              .      .      . 

...        28 

7                 2f,  .  0 

When  gangrene  occurs  in  diabetics,  it  is  usually  after  the  disease 
has  existed  for  several  years.  In  Table  1N5  it  will  be  seen  that  11 
cases  appeared  before  the  disease  had  lasted  four  years,  but  two- 
thirds  of  the  cases  developed  after  that  period.  The  duration  of  the 
existence  of  the  diabetes  preceding  the  gangrene  is  here  shown: 

TABLE  185. — DURATION  OF  DIABETES  PRECEDING  GANGRENE. 


Years.  No.  of  eases. 

Under  1  year.         7  209,  252,  202,  2SS,  470,  517,  725 

1      3      "  1  403 

3  4      "  3  3M>,  3S9,  955 

4  5      "  3  S4,  250,  343 

5  10      "  9  150,  340,  420.  4SO,  525,  035,  1010,  1053,  1072 

10  20      "  12  47,  5S,  210,  237,  355,  404,  505,  093,  749,  SOS,  S30,  1111 

Uncertain  2  25s,  ts93 

The  con<lition  of  the  arteries  and  veins  of  extremities  amputated 
for  gangrene  has  been  carefully  investigated  by  Buerger.1  He  writes : 
"A  study  of  the  condition  of  the  arteries  and  veins  in  limbs  ampu- 
tated for  so-called  diabetic  gangrene  reveals  the  fact  that,  in  each 
and  every  instance  we  are  dealing  not  with  a  gangrenous  process 
due  to  the  diabetes  j>cr  .sv  but  a  mortifying  process  dependent 
upon  extensive  arterial  disease.  .  .  .  In  short,  characteristic  for 
so-called  diabetic  gangrene  is  the  presence  of  the  typical  lesions 
of  athero-  or  arteriosclerosis.  These  differ  in  no  way  from  the 
lesions  of  the  arteries  of  the  arterioselerotic  or  senile  gangrene, 
and  justify  the  conclusion  that  in  diabetic  gangrene  we  are  dealing 
with  an  atherosclerotic  or  arterioselerotic  process." 

The  causes  of  gangrene  develop  slowly,  and  consequently  gan- 
grene itself  is  usually  preceded  by  a  long  duration  of  symptoms. 
(  harcot  pointed  out  intermittent  claudication  as  a  precursor  of 

^er:  Archives  of  Diagnosis,  April,  1915. 


TREATMENT  OF  COMPLICATIONS  425 

gangrene,  and  coldness  of  the  extremities  and  numbness  and  pains 
in  the  feet  are  common  signs  of  approaching  danger. 

The  prophylactic  treatment  of  gangrene  is  seldom  preached,  but 
it  is  important.  All  the  measures  which  are  suddenly  advised  when 
gangrene  appears  should  have  been  adopted  in  a  modified  and 
appropriate  form  years  before  its  appearance.  First  and  foremost 
the  emphasis  in  prophylaxis  must  be  placed  on  treatment  of  the 
diabetes,  and  those  conditions  which  might  predispose  to  arterio- 
sclerosis. The  treatment  of  the  diabetes  follows  the  same  lines 
which  have  been  laid  down  in  the  preceding  sections,  and  the 
treatment  of  the  arteriosclerosis  need  not  be  discussed  here.  The 
most  important  dietetic  considerations  are  the  avoidance  of  acid 
poisoning,  the  use  of  a  low  protein  diet,  and  the  maintenance  of 
the  weight  of  the  patient  by  varying  amounts  of  fat.  Treatment 
of  the  patient  as  a  whole  should  be  directed  to  improvement  of  gen- 
eral circulation,  especially  that  of  the  lower  extremities.  Patients 
predisposed  to  gangrene  must  be  urged  to  walk  for  short  intervals 
several  times  a  day,  and  then  regularly  three  times  a  day  go  through 
such  gymnastic  exercises  as  will  bring  about  a  free  now  of  blood 
throughout  the  feet.  Patients  should  not  remain  long  in  one  posi- 
tion. When  sitting  it  is  desirable  to  use  a  cricket  (in  New  England, 
but  a  "foot  rest"  in  other  sections  of  the  country).  Hot  foot-baths 
should  be  encouraged,  and  hot-air  baths  may  be  employed.  In 
carrying  out  these  procedures  care  should  be  taken  to  avoid 
exhausting  the  patient  by  so  arranging  beforehand  that  the  patient 
will  be  comfortable  during  the  application  of  treatment.  Beware 
of  burns.  Whereas  active  hyperemia  will  improve  the  circulation, 
passive  hyperemia  is  dangerous  and  should  never  be  employed. 

The  treatment  of  actual  gangrene  demands  the  closest  cooperation 
oetween  physician  and  surgeon.  Treatment  should  be  prompt 
and  energetic — delay  is  dangerous.  Stetten,1  a  surgeon,  in  an 
excellent  paper,  reports  remarkable  results  in  the  conservative 
treatment  of  gangrene,  but  it  is  evident  that  his  results  were  due 
first  to  the  fact  that  he  was  a  surgeon  with  an  extensive  surgical 
experience,  and  not  a  general  practitioner,  and  second  to  the  fact 
that  the  medical  treatment  which  he  gave  his  patients  was  along 
modern  lines.  His  results  show  what  can  be  done.  While  undoubt- 
edly early  cases  may  do  far  better  than  formerly  with  medical 
treatment,  and  often  apparently  hopeless  cases  may  clear  up, 
the  physician  who  expects  quick  results  should  control  his  own 
opinion  as  to  the  favorable  progress  of  the  disease  by  that  of  his 
surgical  colleague.  Don't  try  to  see  how  near  the  danger-point 
you  can  go  before  surgical  interference.  Too  often  surgical  treat- 

1  Stetten:  Jour.  Am.  Med.  A^n.,  1913,  Ix,  p.  1120. 


42()  T  It  K  ATM  EXT 

ment  applied  by  physicians  is  atrocious,  and  I  always  long  to  see 
a  real  surgeon  called  in.  Procrastinating  medical  methods  often 
do  far  more  damage  than  prompt  surgical  intervention.  Even  in 
the  old  days  early  operation  usually  resulted  in  recovery,  but  when 
the  patient  was  put  through  a  fat-protein  diet  for  weeks  and  then 
the  surgeon  was  called  upon  to  amputate  in  the  presence  of  acid 
poisoning,  death  frequently  occurred,  as  we  might  expect;  but  it 
was  not  the  operation  which  caused  the  death,  but  the  poor  medical 
treatment  prior  to  the  operation  which  the  physician  prescribed. 

Stctten  recommends  (\)  treatment  for  the  diabetes,  and  this  has 
already  been  described;  ('2)  the  use  of  active  hyperemia  already 
referred  to,  and  (o)  local  treatment.  Absolute  rest  of  the  part  is 
essential  and  the  strictest  asepsis.  Moist  dressings  of  sterile 
physiological  salt  solution  are  to  be  constantly  applied  and  changed 
twice  a  day;  antiseptics  are  to  be  avoided;  beware  of  tight  ban- 
daging; the  extremity  should  be  immersed  twice  a  day  in  sterile 
salt  solution,  and  in  this  the  dressings  may  be  soaked  off.  If  the 
extremity  is  to  be  baked  the  dressings  may  be  left  on,  but  the 
greatest  precaution  should  be  taken  to  prevent  a  burn.  Treat  the 
wound  tenderly.  Avoid  forcible  removal  of  sloughs.  In  general,  rely 
upon  expectant  treatment,  but  do  not  hesitate  to  open  pockets  of  pus. 

If  operation  is  necessary,  use  nitrous  oxide  or  nitrons  oxide  and 
oxygen  or  spinal  anesthesia,  but  avoid  ether  and  under  no  circum- 
stances use  chloroform.  Local  anesthesia  is  objectionable  because 
of  trauma  to  the  part.  Spinal  anesthesia  may  be  employed.  1  hiring 
the  operation  avoid  the  use  of  an  Esmarch  bandage.  The  absence 
of  a  palpable  pulse  in  a  popliteal  space  is  not  a  contra-indication  to 
amputation  below  the  knee,  and  a  low  amputation  is  by  no  means 
to  be  shunned.  The  postoperative  care  of  the  patient,  demands  the 
best  of  nursing.  The  patient  should  be  frequently  turned  from  side 
to  side  and  should  be  urged  to  take  deep  breathing  exercises.  Older 
writers  discredited  operative  measures  when  acid  poisoning  was 
present.  Today  we  know  that  the  appearance  of  acid  poisoning 
should  be  prevented,  and  that  if  it  occurs  it  can  usually  be  dispelled 
by  feeding  small  quantities  of  carbohydrate  .">  per  cent,  vegetables 
and  one  or  two  oranges  but  otherwise  no  food,  and  subsequently 
the  operation  may  take  place. 

TAISLK   1X0. — Dnt.vno.v  OF  I, IKK  OF   DIAHKTIC   PATIK.VTS  AFTF.K  OXSF.T 

OF  (  !A.\<;KI:\K. 


Living. 
s     I'ndcr  1.      1      :;      1 

~T~:7T'T 


TREATMENT  OF  COMPLICATIONS  427 

Results. — The  duration  of  life  of  diabetic  patients  after  the  onset 
of  gangrene  has  varied  in  my  37  cases  from  less  than  one  year  to 
eight  years.  The  details  are  shown  in  Table  180. 

From  the  above  table  it  will  be  observed  that  among  the  fatal 
cases,  two-thirds  succumbed  to  the  disease  within  the  first  year, 
whereas  among  the  living  cases  two-thirds  have  already  gone 
beyond  the  first  year.  I  see  no  reason  why  statistics  for  this  com- 
plication in  diabetes  should  not  rapidly  improve.  In  my  recent 
fatal  cases  the  explanation  of  failure  lies  in  manifest  errors  in  treat- 
ment, either  made  by  myself  or  by  other  physicians.  Mistakes  have 
been  so  plain  that  they  should  readily  be  avoided  in  the  future. 
(Seep.  71.)  Operations  were  performed  upon  18  of  the  patients, 
and  the  remaining  19  were  treated  medically.  Table  187  leaves 
little  doubt  as  to  the  efficacy  of  the  two  methods : 

TABLE  187. — OPERATIVE  AXD  XOX-OPERATIVE  TREATMENT  OF  DIABETIC 
PATIEXTS  WITH  GANGRENE. 


Duration  of      '  Surgical  treatment 

life  after  onset 
of  gangrene. 


Fatal. 

Living. 

Fatal.                    Living. 

Years 


Uncer-  |  Under 
tain.          1. 


12       13 


13         111 


1 


Of  the  18  cases  treated  surgically,  4  are  still  alive,  but  of  the  19 
treated  medically  I  know  of  but  2.  Furthermore,  of  the  18  cases 
treated  surgically,  7,  or  39  per  cent.,  died  during  the  first  year, 
but  of  the  19  cases  treated  medically,  15,  or  79  per  cent.,  suc- 
cumbed during  the  same  period. 

The  surgical  treatment  of  diabetic  gangrene,  in  my  experience, 
though  executed  by  many  different  surgeons  (under  all  sorts  of 
conditions),  and  with  gangrene  extending  over  varying  lengths  of 
time  has  been  twice  as  successful  as  medical  treatment. 

There  is  little  doubt  in  my  mind  but  that  if  the  beginning  of 
gangrene  was  as  noisily  ushered  in  as  an  attack  of  biliary  or  renal 
colic  the  results  of  treatment  would  be  far  different.  Death  from 
gangrene  is  frequently  now,  as  in  the  past,  the  result  of  procrasti- 
nation on  the  part  of  the  physician  and  patient,  the  inauguration 
of  a  fat-protein  diet  and  ether  anesthesia.  Surgery  often  receives, 
but  seldom  deserves,  the  blame  of  a  fatal  issue. 

5.  Care  of  the  Skin. — Pruritus,  Furunculosis,  Carbuncles. — Pruritus 
frequently  occurs  in  diabetes.  Pruritus  pudendi  invariably  will 
vanish  within  a  few  days  after  the  disappearance  of  sugar  from  the 
urine,  but  general  pruritus  may  be  annoying  and  persist  for  weeks. 


42S  THE  ATM  EXT 

I  do  not  remember  to  have  observed  its  presence  in  young  diabetics. 
Yon  Xoorden  has  found  sodium  salicylate  internally  almost  a 
specific  in  the  treatment  of  general  pruritus.  In  using  it  bear  in 
mind  the  confusion  which  may  follow  in  examining  the  urine  for 
sugar  and  diacetic  acid.  I  have  not  employed  it.  If  pruritus 
pudendi  does  not  clear  up  promptly,  as  the  urine  becomes  sugar- 
free,  an  examination  will  probably  disclose  a  prolapse,  leucorrhea 
or  urinary  incontinence.  Ixest  in  bed,  absolute  cleanliness,  simple 
douches,  and  the  simplest  of  ointments,  are  indicated.  The  free 
use  of  oil  to  prevent  irritation  during  micturition  is  helpful.  I  have 
known  applications  of  yeast  and  water  (yeast  cake  rubbed  up  with 
1200  to  500  c.c.  of  water)  to  be  efficacious.  It  is  well  to  bear  in 
mind  that  patients  with  chronic  nephritis  are  often  relieved  of  pru- 
ritus when  the  protein  in  the  diet  is  reduced. 

Infections  of  the  skin  are  apparently  less  common  now  than 
formerly  and  this  may  be  attributed  to  the  improved  hygiene. 
Such  infections  are  and  should  be  rare  in  diabetic  patients  under 
treatment.  They  demand  immediate,  thorough,  yet  gentle,  treat- 
ment. One  of  the  first  duties  of  the  physician  is  to  tell  diabetic 
patients  to  keep  the  skin  clean  and  to  report  the  beginning  of  an 
infection  at  once.  Patients  should  be  warned  of  the  danger  from 
slight  wounds,  should  specifically  be  advised  not  to  allow  mani- 
curists or  chiropodists  to  draw  a  drop  of  blood,  and  cautioned  to 
promptly  report  any  injury  to  the  skin.  Absolute  cleanliness  of 
the  body  is  essential.  Formerly  the  increased  percentage  of  sugar 
in  the  tissues  was  held  responsible  for  the  presence  of  infections, 
but  recent  work  has  tended  to  disprove  this  theory.  It  is  of  interest 
that  von  Xoorden  has  observed  such  infections  to  be  more  common 
soon  after  the  development  of  diabetes  than  when  the  cases  were 
well  established.  One  would  expect  the  reverse  if  either  the  sugar 
or  acid  in  the  tissues  predisposed  to  infection,  because'  these  tend 
to  increase  as  the  diabetes  progresses.  Subcutaneous  injections, 
whether  of  water,  salt,  solution  or  drugs,  should  be  avoided.  It  is 
common  for  salt  solution  or  solutions  of  sodium  bicarbonate',  when 
injected  subpectorally,  to  result  in  abscess.  If  there  is  the  slightest 
tendency  to  fnrunculosis,  1  at  once  adopt  simple1  measures  analo- 
gous to  those  described  by  Bowen.1  The  patient  is  advised  to  wash 
the  whole  body  twice  a  day  with  soap  and  water,  using  a  wash  cloth 
or  piece  of  flannel,  and  to  dry  the  skin  without  rubbing,  so  as  to 
avoid  breaking  open  any  pustule;  the  whole  body  is  then  bathed 
with  a  saturated  solution  of  boracic  acid  in  water,  with  the  addition 
of  a  small  proportion  of  camphor  water  and  glycerin.  I  have  often 
used  a  solution  of  two  parts  alcohol  and  one  part  water  to  advantage, 

1  Hovvon:  Jour.  Am.  Mt'd.  Assn.,  1010.  Iv,  p.  201);  Boston  Mod.  and  Sur«.  Jour., 
1017,  <-lx  ;vi,  [).  90. 


TREATMENT  OF  COMPLICATIONS  429 

but  I  notice  that  Bowen  in  his  second  paper  still  prefers  the  boracic 
acid.  Individual  furuncles  may  be  treated  with  the  following 
ointment  according  to  Bowen: 

Boracic  acid 4 

Precipitated  sulphur 4 

Carbolated  petrolatum  . 30 

One  should  be  careful,  however,  not  to  overtreat  the  skin.  Harm 
may  result  from  frequent  dressings.  The  simplest  lotions  should 
always  be  employed.  In  severe  cases  the  patient  should  be  put  to 
bed,  all  linen  changed  twice  daily,  and  the  patient  treated  in  as 
aseptic  a  way  as  possible.  In  a  few  cases  vaccines  have  appeared 
to  be  of  marked  benefit.  "This  procedure,  thorough  bathing  and 
soaping,  the  application  of  the  borated  solution,  and  the  dressing 
of  the  individual  furuncles,  is  repeated,  as  has  been  said,  morning 
and  night.  A  further  point  of  vital  importance  relates  to  the  clothing 
that  is  worn  next  to  the  skin.  Every  stitch  of  linen  worn  next  to  the 
skin  should.be  changed  daily,  and  in  the  case  of  extensive  furuncu- 
losis  all  the  bedclothing  that  touches  the  individual,  as  well  as  the 
night-clothing,  should  be  subjected  to  a  daily  change.  Naturally, 
this  treatment  must  be  continued  for  several  weeks  after  the  last 
evidence  of  pyogenic  infection  has  appeared,  and  this  fact  must  be 
emphasized  to  the  patient  at  the  outset."  (Bowen.) 

Energetic  dietetic  treatment  does  not  show  so  satisfactory  resul.ts 
in  the  presence  of  furunculosis  as  in  pruritus  pudendi.  Infections 
greatly  increase  the  difficulty  of  rendering  the  urine  sugar-free, 
and  a  small  boil  may  cause  a  trace  of  sugar  to  persist  for  days.  It 
is  easy  to  keep  the  patient  on  a  low  diet  too  long.  These  patients 
require  the  most  careful  management,  and  as  acidosis  easily  develops 
all  the  measures  adopted  to  prevent  and  combat  acidosis  should  be 
employed.  Neglected  cases  are  the  most  dangerous. 

Carbuncles  cause  the  death,  directly  or  indirectly,  of  many  a 
case  of  diabetes.  It  is  remarkable,  however,  how  satisfactorily 
these  can  be  treated,  provided  that  prompt  measures  are  adopted 
from  the  beginning.  The  urine  of  the  patient  should  at  once  be 
made  sugar-  and  acid-free,  and  the  very  best  surgical  skill  invoked. 
Bungling  medical  surgery  is  painful  to  behold.  In  connection 
with  dietetic  and  surgical  treatment,  vaccines  may  be  used  with 
advantage. 

Fourteen  cases  of  carbuncles  were  readily  found  in  my  records, 
but  I  am  sure  that  others  exist.  Of  this  number  death  followed 
the  carbuncle  in  at  least  five  instances.  It  is  my  impression  that 
a  good  prognosis  can  be  given  provided  treatment  is  begun  early. 
The  surgeon  should  be  encouraged  to  adopt  the  same  measures 
which  he  would  adopt  in  a  non-diabetic  individual. 


430  TREATMENT 

Metnstases  resulting  from  the  carbuncle  were  numerous  in  two 
of  the  cases:  No.  ">lo  and  NO.  77(>. 

Case  No.  ")!:•)  is  reported  under  Cases  Unsuccessfully  Treated  by 
Fasting,  p.  '.ft'.}.  Case  No.  77(1,  age  at  onset  fifty-two,  li)()S,  first 
seen  thirty-four  days  after  the  beginning  of  a  carbuncle  in  Octo- 
ber, 1914.  At  the  time  there  was  extensive  ulceration  in  the 
neck;  '.}.()  per  cent,  of  sugar  in  the  urine.  lie  died  five  weeks 
later  with  metastatic  abscesses  and  undoubted  septicemia.  Case 
No.  901  (see  p.  '.ftO)  died  finally  of  coma  with  extension  of  the 
carbuncle. 

An  apparently  hopeless  case  may  recover.  Such  was  Case  No. 
Sl 7;  age  at  onset  of  diabetes,  seventy-two;  first  seen  a  year  later,  in 
-January,  191"),  ten  days  after  the  beginning  of  a  carbuncle.  Urine 
2400  c.c.,  4.2  per  cent,  of  sugar.  Examination  showed  two  car- 
buncles on  back  of  the  neck,  extensive  ulceration  on  the  right  side 
of  the  neck  and  another  area  of  ulceration  in  front.  The  physician 
described  him  as  "drowsy  by  day  and  delirious  by  night."  On 
account  of  his  age  and  pitiable  condition,  it  was  debated  by  those 
in  attendance  as  to  whether  it  was  justifiable  to  even  attempt 
further' medical  or  surgical  treatment.  Finally  fasting  was  begun, 
with  the  result  that  he  became  sugar-free,  and,  except,  for  a  brief 
interval,  has  remained  so  ever  since  (December  1,  1910). 

In  July,  191"),  the  patient  was  eating  vegetables,  a  little  fruit 
and  potato  twice  daily,  and  felt  well  save  for  extensive  pruritus. 
The  insomnia  which  this  caused  made  him  miserable,  but  he  was 
well  enough  to  relieve  it  by  spending  his  evenings  at  Revere  Beach 
picture  shows. 

Christie's1  case  was  severe,  frequently  showing  high  dextrose- 
nitrogen  ratios  while  taking  12  grams  sodium  bicarbonate  daily, 
was  fasted  eleven  days,  and  was  finally  discharged  sugar-free  upon 
a  diet  containing  carbohydrate'  DO  grams,  protein  ">.">  grams,  and  fat 
22.")  grams.  No  operation  upon  the  carbuncle  was  performed. 

(i.  Care  of  the  Teeth. — Many  diabetic  patients  have  poor  teeth 
or  no  teeth  at  all.  Approximately  41  per  cent,  of  .'>()()  cases  recently 
seen  had  either  poor  or  false  teeth.  Poor  teeth  are  by  no  means 
necessary,  even  in  diabetes  of  long  duration.  Cases  which  are 
carefully  treated  from  the  outset  and  are  cautioned  about  care  of 
the  teeth  have  little  more  trouble  than  healthy  individuals.  Then, 
too,  patients  with  diabetes  of  long  duration  are  occasionally  seen 
with  perfect  teeth.  It  is  my  impression  that  the  changes  in  the 
teeth  an'  subsequent  to  the  onset  of  the  diabetes,  but  I  am  open  to 
conviction  upon  this  point. 

It  is  never  advisable,  however,  to  advocate  radical  treatment  of 

1  Christie;  Jour.  Am.  Mod.  Assn.,    1017,  Ixviii,  p.  170. 


TREATMENT  OF  COMPLICATIONS  431 

the  inflamed  gums  at  the  outset,  or  to  allow  seemingly  poor  teeth 
to  be  extracted.  Over  and  over  again,  as  a  result  of  constitutional 
treatment,  the  condition  of  the  mouth  improves,  and  loosened 
teeth  become  firm.  Only  when  it  it  seen  that  further  progress  is 
not  to  be  expected  should  operative  measures  be  employed. 

The  extraction  of  teeth  has  probably  often  resulted  in  the  death 
of  the  patient,  due  presumably  to  the  anesthetic.  In  illustration 
of  this  point  I  would  cite  Case  No.  729. 

(o)  Death  Subsequent  to  Extraction  of  Teeth — Ether  Anesthesia. — 
Case  No.  729,  female,  married,  teacher,  first  seen  May  1C),  1914; 
no  diabetic  heredity.  Greatest  weight  163  pounds,  but  124  at  the 
first  visit.  One  child  born  in  1905  and  well.  In  September,  1907, 
sugar  first  found  while  five  months  pregnant.  Confinement  was 
normal,  and  the  child  is  living  and  well.  The  patient  became  sugar- 
free  and  remained  so  until  January,  1911,  when  she  was  again 
pregnant,  but  miscarried  in  the  following  March.  In  July,  1911, 
she  became  pregnant  and  the  child  was  born  at  term  and  is  also  well. 
Sugar  was  absent  at  this  time,  but  it  soon  came  back  and  persisted. 
A  miscarriage  occurred  in  February,  1914,  and  there  was  a  history 
of  two  other  miscarriages.  Under  dietetic  treatment  at  the  New 
Kngland  Deaconess  Hospital  in  June.  1914,  the  sugar  decreased 
from  G.2  per  cent,  to  zero,  and  the  patient  acquired  a  tolerance 
varying  between  15  and  45  grams.  On  April  2(>,  1915,  three  months 
after  her  last  visit  to  me  and  without  my  knowledge,  all  her  teeth 
were  taken  out  with  ether  as  an  anesthetic.  The  extraction  took 
place  at  the  dentist's  office.  "  She  was  very  sick  after  getting  home, 
and  all  that  night  and  the  next  day  complained  of  the  awful  weakness 
and  pressure,  so  that  it  was  hard  for  her  to  breathe.  April  28  her 
mind  was  wandering,  and  it  was  difficult  to  bring  her  back  to  con- 
sciousness." She  died  in  coma  April  30,  1915. 

In  contrast  I  would  cite  Case  No.  753,  age  at  onset  thirty- three, 
who  first  came  under  observation  at  the  age  of  thirty-nine,  in  July, 
1914.  He  was  seen  only  once,  but  on  October  28,  1915,  entered  the 
hospital  and  the  course  of  the  case  is  shown  by  Table  188. 

On  [Monday,  November  15,  the  patient  was  given  gas  and  oxygen 
by  Dr.  Freeman  Allen  and  the  teeth  extracted  by  Dr.  Ashland, 
who  took  great  pains  to  avoid  trauma.  The  patient  was  up  and 
about  the  ward  the  same  evening,  and  so  comfortable  as  to  attend 
the  nine  o'clock  clinic  the  next  morning,  and  two  days  later  started 
for  home  with  gums  practically  healed.  (See  also  p.  341). 

The  same  rules  which  govern  the  use  of  anesthetics  in  surgery 
apply  in  dentistry.  Gas  or  gas  and  oxygen  are  undoubtedly  the 
best  anesthetics.  Novocain  may  be  advantageously  employed  and 
obviates  in  these  days  the  dangers  of  general  anesthesia,  but  it 
should  be  used  with  caution  because  the  infiltration  of  the  tissues 


432 


TREATMENT 


may  be  distinctly  harmful.  The  following  suggestions  are  based 
upon  notes  made  for  me  by  Dr.  W.  I.  Ashland,  to  whom  1  am  much 
indebted  for  tins  and  other  favors. 

TABLE  1SS. — ILLUSTRATION'  OF  USE  OF  GAS  AND  OXYGEN  AS  AN  ANESTHETIC 
WITHOUT  SUBSEQUENT  Aciuosis.     CASK  No.  7/53. 


>. 

= 

Diet  (grains). 

-^         1.           ~ 

C              - 

•  r                v;             u- 

— 

^          5       c         L. 

Dato. 

0             tj 

" 

-            S 

^3 

~  ~          & 

"« 

0                    0 

.S 

M                      7 

i    C           S 

?•       _E'  -       *-' 

•r.     •           ~ 

~             -~ 

_ 

^  "  J 

•—          c  •*         — 

—   —            ~   — 

=              o 

-                                     ^5                             ^ 

—   >.          ^ 

o         —  -          -1 

-   c            ~    - 

-                 X 

.—                                 — 

—  '  —  •           ^ 

"3               ~*              "i  — 

".   ~-            <~   *~ 

--           -f. 

O                         ?H 

t-       c 

^ 

£ 

K 

< 

1014 

Julv    20      2400      1035          0 

98 

30      3420       10H7           0 

138 

Dor.    11       40SO 

103(1 

0 

08 

L915 

Fob.    14      3300 

1030 

0 

30 

Oct      2S 

1  ''OO 

1031 

1     !     ! 

1)     ()O 

193 

30 

20        000 

14 

20           5 

100 

+   0      124 

30        SOO 

0        j      .  . 

0           0 

3         12 

123      0.18 

31         050 

1021 

0 

0 

0          0 

3         12 

Nov.     0      1050      1023          0 

0 

20        01 

72     1  (X)s 

+20      120 

14      1000         ...        0 

0 

15  ,    1050      1010          0       ,      .  .            0 

0          0 

0          0         .  .         110 

Tooth  extracted  —  an 

cstlu  lie,    u 
,_ 

as   an  d  oxy  iron. 

10       1OOO 

0             .  .            0 

n      2; 

30       ,)!.>       J-M 

"So  soon  as  diabetes  is  diagnosed,  dental  prophylaxis  should  begin. 
Regular  visits  at  frequent  intervals  should  be  made  to  the  dentist 
in  order  that  the  teeth  may  be  thoroughly  cleaned.  The  dentist 
should  take  great  pains  not  to  injure  the  gums.  Free  food  de-posit 
should  be  removed  from  the  teeth  surfaces,  but  no  attempt  made 
to  scale  under  the  gums.  The  teeth  should  be  carefully  polished 
with  a  rubber  disk  and  not  touched  with  a  rotary  brush.  Later, 
when  the  diabetes  is  under  control,  the  teeth  may  be  more  thor- 
oughly cleaned,  and  all  calculus  removed.  As  this  is  an  exceedingly 
difficult  task,  two  separate  appointments  should  be  made.  The 
gums  may  then  be  lightly  touched  with  tincture  of  iodine. 

"A  tooth-brush  should  be  medium  sized,  with  soft  bristles.  A 
tuft  arrangement  of  bristles  is  excellent  or  those  spaced  about  an 
eighth  of  an  inch  apart,  because  either  of  these  types  of  brushes 
will  allow  the  spaces  between  the  teeth  to  be  reached.  A  rubber 
tooth-brush  may  he  employed  in  cases  with  inflamed  gums,  although 
the  best  results  cannot  be  obtained  with  this  type  of  brush.  The 
material  which  cannot  be  removed  in  this  manner  had  better  be 
left  Ifor  the  dentist.  A  second  brush  with  two  or  three  rows  of 
bristes  might  advantageously  be  used  for  cleaning  isolated  teeth. 

"Any  tooth  powder  or  tooth  past*'  may  be  used  providing  it  is 
not  gritty.  A  paste  is  the  more  convenient,  economical,  and  less 
likely  to  contain  gritty  substances.  Pure  precipitated  chalk,  Castile 
soap,  or  even  salt  and  water  may  be  employed. 


TREATMENT  OF  COMPLICATIONS  433 

"Lime  water  or  any  simple  mouth-wash  may  be  used,  but  for 
their  cleansing  properties  rather  than  antiseptic  quality,  which 
they  do  not  possess.  The  mechanical  cleansing  of  the  teeth  is  the 
essential  feature  of  oral  hygiene. 

"The  patient  should  be  told  that  in  cleaning  the  teeth  the  chief 
problem  is  to  cleanse  the  interproximal  spaces  with  a  minimal 
amount  of  injury  to  the  adjacent  tissues.  The  exposed  teeth 
surfaces  require  little  attention.  Do  not  brush  across  the  teeth. 
Do  not  begin  the  brushing  in  the  same  region  twice  in  succession, 
as  when  the  brush  is  first  used  it  will  be  found  harsh. 

"  Before  brushing  the  teeth,  rinse  the  mouth  with  tepid  water,  in 
order  to  remove  free  deposits. 

"The  brush  should  have  a  rigid  handle,  but  be  held  in  the  hand 
with  a  yielding  grip.  Brush  the  teeth  thoughtfully,  with  an  up-and- 
down,  rolling  or  rotary  motion,  touching  the  gums  hardest  on  the 
downward  stroke.  This  will  be  found  difficult  to  accomplish,  but 
practice  will  bring  very  satisfactory  results.  The  teeth  should  be 
brushed  after  each  meal,  upon  rising  and  on  retiring. 

"After  the  use  of  the  brush  the  mouth  should  be  rinsed  with  tepid 
water,  to  remove  any  loose  material  remaining  in  the  mouth. 

"As  an  adjunct  in  the  care  of  the  mouth  and  teeth,  floss  silk 
is  an  absolute  necessity.  The  floss  silk  employed  should  be  fine 
and  preferably  of  the  'ribbon'  type.  The  silk  should  be  carefully 
forced  with  a  sawing  motion  between  the  teeth,  being  especially 
careful  not  to  strike  the  gum  a  sharp  blow.  Push  the  floss  down 
the  side  of  one  tooth  and  up  the  side  of  the  other.  Continue  this 
until  you  have  cleansed  between  all  teeth.  This  should  be  done  at 
night  after  the  last  brushing. 

"After  the  teeth  have  been  brushed  and  flossed,  the  mouth  should 
ne  rinsed  with  lime  water,  and  this  should  complete  the  toilet." 

7.  Constipation  and  Diarrhea. — Constipation  is  the  rule  in  diabetic- 
patients.  It  is  less  common  with  restricted  than  with  excessive 
diet.  Occasionally  one  is  gratified  by  the  abundant  use  of  vegetables 
relieving  an  existing  constipation,  but  this  is  seldom  the  case.  If 
more  care  were  taken  to  select  those  which  lead  to  a  slight  gas  forma- 
tion, such  as  cauliflower,  onions,  cabbage  and  spinach,  better  results 
might  be  secured.  The  gas  prevents  hard  fecal  masses.  Thus  one 
of  my  patients  who  has  a  diabetic  garden  regulates  his  bowels  by 
beginning  his  breakfast  with  a  slice  of  raw  cabbage. 

Constipation  is  a  serious  menace  if  the  caloric  intake  is  large; 
it  has  caused  no  dangerous  symptoms  in  my  experience  when  the 
patient  has  been  fasted.  Constipation  commonly  precedes  coma 
and  seriously  embarrasses  treatment  of  the  same.  Hodgson  empha- 
sizes the  importance  of  keeping  the  bowels  free  in  diabetes,  and  his 
large  experience  deserves  attention. 
28 


434  TREATMENT 

Physical  exercise  is  the  best  treatment  for  constipation.  Since 
I  have  encouraged  the  patients  to  walk  outdoors  five  times  a  day 
and  to  take  up  other  forms  of  exercise,  there  has  been  less  need 
of  drugs  for  constipation.  The  constipation  of  Case  No.  34S, 
whose  prostate  was  successfully  removed  by  Chute,  vanished  when 
lie  began  to  saw  wood. 

Musfidye.—  Mr.  Gnstaf  Sundelius,  who  has  been  of  so  much  help  in 
giving  massage  and  exercises  to  my  patients  with  inanition  and  gan- 
grene, and  in  training  them  to  massage  and  exercise  themselves,  has 
furnished  me  the  following  sets  of  exercises  for  the  relief  of 
constipation. 

HOME  EXERCISES  FOR  CONSTIPATION  (SUNDELIUS). 

Group  1. — Eaxy  to  Execute,  Suitable  for  Weal;  and  Elderly  People. 

1.  Abdominal  Kneading  and  Stroking. —  Kneading. — Lying  down, 
with   knees   slightly  drawn   up.     Place  hands  one   on  top   of  the 
other    on  the  abdomen  at    the  right    groin;  with    small    circular 
movements  and  deep  pressure  work  upward  until  the  ribs  are  met, 
then  across  toward   left,  following  the  boundary  line   of  the  chest, 
then   downward  to  the  left  groin.     Repeat  twenty  to   fifty  times. 
Stroking.     With  hands  similarly   placed,   make  long,   steady   and 
deep  strokes  following  the  same  route.     Repeat  twenty-five  to  one 
hundred  times. 

2.  Ley  Rolling. — Lying  down,  take  hold  of  both  legs  just  below 
the  knees,  press  the  knees  up  close  to  the  abdomen,  then  carry  them 
apart,  then  down  and  inward  until  they   meet  again,  thus  letting 
the  knees  describe  two  circles.     Repeat  ten  to  twenty  times. 

'.\.  Abdominal  Compression. — Standing  against  the  wall  with  hands 
clasped  behind  neck,  draw  the  abdomen  forcibly  in,  using  the  abdom- 
inal muscles,  hold  a  second,  then  let  go.  Repeat  ten  to  forty  times. 

4.  Trunk  liolling.—  Standing  with  hands  on  hips,  feet  apart  and 
legs  well  stretched,  roll  the  upper  body  in  a  circle  on  the  hips  by 
bending    forward,  to  the  left,   backward  and  to    the   right.     Then 
reverse,  and  repeat  six  to  twelve  times  each  way. 

(iron])  2. —  lieiptlre  More  Force  ami  Should  be  Uxed  by  Strong 

People  Only. 

5.  Leg  Lifting,  Single  and    Double.     Lying  on  the  bed,  or  better 
still,  on  the  carpeted  floor,  with  hands  clasped  behind  neck,  lift  the 
well-stretched  legs  way  up,  slowly  letting  them  down  again,  either 
alternately  or  both  together,    Repeat  six  to  twenty  times. 


TREATMENT  OF  COMPLICATIONS  435 

6.  Trunk  Bending  Sidewise. — Standing-with  hands  clasped  behind 
neck,  bend  body  way  over  to  the  left,  then  back,  in  upright  posi- 
tion and  then  over  to  the  right.    Stop  a  second  at  the  extreme 
bend  positions.     Repeat  five  to  ten  times. 

7.  Trunk  Bending  Forward  and  Bade /card. — Standing  with  arms 
straight  up  in  the  air,  bend  forward   as  far  as  can   be  done  without 
bending  the  knees,  then  upward  and  slightly  backward.     Repeat 
six  to  ten  times. 

8.  Trunk  Falling  Backward. — Sitting  on  a  stool,  with  hands  on 
hips,  legs   outstretched  and  feet  braced  under  some  heavy  object 
(for  instance,  a  radiator),  let  the  upper  body  slowly  fall  backward, 
then  raise  to  sitting  position  and  repeat  four  to  eight  times. 

Mineral  oil,  salts,  and  enemata  can  be  used  when  active  treatment 
is  necessary,  but  when  daily  measures  are  required  one  should 
attempt  to  depend  upon  the  diet.  If  the  patient's  tolerance  allows 
the  use  of  an  orange  in  addition  to  5  per  cent,  vegetables,  frequently 
nothing  more  is  necessary.  Great  pains,  however,  should  be  taken 
to  impress  upon  the  patients  the  necessity  of  preparing  coarse 
vegetables  in  a  simple  manner.  It  is  perfectly  possible  to  cook 
cabbage,  cauliflower,  turnips,  parsnips,  radishes,  cucumbers,  and 
onions  so  as  to  be  unirritating  to  the  digestive  tract  and  yet  preserve 
their  laxative  qualities.  Patients  whose  tolerance  allows  potatoes 
are  encouraged  to  eat  them  with  the  skins  on.  Diarrhea  should  be 
carefully  avoided. 

Drugs  which  I  have  found  most  satisfactory  have  been  cascara 
sagrada,  compound  rhubarb  pills,  aloin,  strychnin  and  belladonna 
tablets,  or  aloin  alone. 

The  possibility  of  prolonging  acid  poisoning  by  the  use  of  castor 
oil  must  be  borne  in  mind. 

Mineral  oil  may  be  advantageously  employed.  Once  a  positive 
ferric  chloride  reaction  followed  its  use  without  any  other  known 
cause.  The  oil  may  have  been  adulterated,  for  one  could  not  expect 
the  mineral  oil  to  be  burned  in  the  body.  The  various  aperient 
waters  may  be  employed,  but  loose  movements  should  be  avoided. 
Sodium  or  magnesium  citrate  in  doses  of  one  or  two  teaspoonfuls 
helps  to  relieve  the  constipation,  but  the  alkali  which  it  furnishes 
may  prolong  the  presence  of  a  diacetic  acid  reaction.  Bran  bread 
is  often  helpful  (see  pp.  5!)5  and  531 ). 

Diarrhea  is  a  most  serious  complication.  Rest  in  bed,  fasting 
and  preservation  of  body  warmth  should  be  carried  out  from 
beginning  to  end  of  the  attack.  Hot  water,  solutions  of  hot,  weak 
tea,  cracked  cocoa,  and  brandy  may  be  given.  When  the  indication 
is  plain  the  bowels  should  be  cleared  out  with  castor  oil,  or  what 
I  find  works  far  better,  half  a  Seidlitz  powder.  Avoid  strong 


430  TREATMENT 

cachartics,  for  diabetic  patients  with  diarrhea  are  usually  too  feeble 
to  withstand  their  action.  Should  the  cause  of  the  diarrhea  below 
down  in  the  intestinal  tract,  eneinata  should  be  used.  If  any  drug 
is  employed,  it  should  be  opium.  The  return  to  the  diabetic  diet 
is  rendered  easy  by  the  use  of  sugar-free  milk,  lean  meats,  eggs, 
gelatin,  and  vegetables  which  have  been  most  carefully  prepared  and 
sieved.  These  carefully  prepared,  tender  vegetables  are  frequently 
better  borne  than  a  diet  containing  considerable  quantities  of 
albuminous  and  fatty  food.  If  the  carbohydrate  tolerance  allows, 
oatmeal  gruel  in  divided  portions  is  most  desirable. 

Calcium  carbonate  in  doses  of  1  or  '2  grams  has  been  employed  to 
offset  the  diarrhea  which  occasionally  occurred  when  sodium  bicar- 
bonate was  freely  given. 

X.  Neuritis. — Neuritis  yields  as  obstinately  to  treatment  in  dia- 
betes as  when  it  occurs  associated  with  other  diseases.  Unfortunately 
it  does  not  always  disappear  with  the  removal  of  the  glycosuria. 
Possibly  this  may  be  accounted  for  by  an  increased  quantity  of 
sugar  persisting  in  the  blood  long  after  it  has  disappeared  from  the 
urine.  The  most  Frequent  type  of  neuritis  which  occurs  in  diabetes 
is  sciatica.  From  the  help  which  modern  orthopedic  treatment  has 
afforded  my  patients,  I  am  inclined  to  consider  the  development  of 
sciatica  as  having  little  causal  connection  with  the  disease,  except 
insofar  as  such  a  complication  may  appear  in  any  individual  who 
lias  lost  weight  and  whose  muscles  afford  only  lax  support  to  the 
large  joints.  Hydrotherapeutic  measures  avail  much,  but  fixation 
of  the  back,  particularly  of  the  sacro-iliac  joints,  brings  most  relief, 
as  my  orthopedic  friends  have  been  able  to  demonstrate  upon 
intractable  cases.  In  some  cases  of  this  type  symptoms  persist 
despite  such  treatment,  but  sometimes  these  can  be  explained  as 
habit  pains.  Moist  flannel  applications  changed  every  one  or  two 
minutes  almost,  invariably  give*  comfort.  These  are  appliod  by 
placing  a  dry  flannel  upon  the  skin,  for  the  sake  of  protection,  with 
the  moist,  hot,  freshly  wrung-out  flannel  laid  over  it  and  the  pro- 
truding ends  of  the  dry  flannel  covered  over  to  retain  the  heat  and 
meanwhile  a  third  flannel  is  kept  in  hot  water  for  future  use.  Dry 
heat  is  less  efficacious.  Applications  of  this  type  continued  for  ten 
minutes  twice  a  day  are  of  the  greatest  assistance  in  lessening  pain. 

Mental  diversion,  brought  about  by  change  in  surroundings, 
often  produces  good  results.  Similarly,  the  improvement  in  the 
general  condition  which  follows  rigorous  dietetic  and  physical  treat- 
ment is  of  great  advantage.  Such  cases  are  particularly  helped  by 
a  brief  stay  in  a  hospital,  or  by  having  a  well-trained  diabetic  nurse 
in  the  home. 

The  type  of  neuritis  almost,  invariably  encountered  has  occurred 
in  the  lower  extremities.  When  diminished  sensation,  pain  and 


TREATMENT  OF  COMPLICATIONS  437 

tenderness  exist,  there  is  always  doubt  whether  the  condition  is  a 
true  neuritis  or  simply  the  result  of  poor  circulation.  It  is  certainly 
true  that  a  pure  type  of  neuritis  in  other  parts  of  the  body  in  diabetes 
is  seldom  seen.  For  this  reason  I  am  inclined  to  believe  that  the 
poor  bloodvessels  of  the  lower  extremities  are  the  chief  offenders. 
Alcohol  is  also  an  important  etiological  factor. 

9.  Eyesight.  —  Ocular  complications  in  diabetes  are  frequent.  Von 
Xoorden  reports  that  of  279  patients,  58.3  per  cent,  had  trouble 
with  the  eyes  attributable  to  the  diabetes,  and  of  those  patients 
over  fifty  years  of  age,  SO  per  cent.  He  summarizes  the  results 
of  the  examination  of  the  eyes  of  477  diabetics,  taken  in  succession. 
Defects  were  found  in  279  instances;  in  259  of  these  cases  there 
was  no  etiological  cause  other  than  the  diabetes.  A  summary  of 
the  data  is  given  in  the  following  table: 


TABLE  ISO.  —  OCULAR  COMPLICATIOX.S  i\  DIABETES  (vox 

Xo.  of  Cases. 

Retinitis   .................  81 

Retrobulbar  neuritis       .............  23 

Atrophy  of  the  optic  nerve       ...........  IS 

Cataract  .................  62 

Iritis    ..................  2 

Amblyopia  without  organic  change     .........  33 

Diabetic  myopia       ..............  21 

Other  conditions       ..............  39 

Fortunately  complications  often  vanish  after  the  patient  has 
been  free  from  sugar  and  acidosis  for  a  few  weeks.  If  treatment 
will  accomplish  so  much  when  complications  have  appeared,  how 
much  it  must  accomplish  in  prevention  of  complications.  One 
cannot  too  frequently  impress  upon  the  patient  that  treatment  is 
instituted  not  simply  to  keep  sugar  out  of  the  urine,  but  to  save 
him  from  a  great  variety  of  serious  incidental  diseases.  Conversely, 
with  the  institution  of  progressive  treatment  the  eyesight  often 
temporarily  fails,  and  I  have  more  than  once  had  patients  in  the 
course  of  a  few  days  become  unable  to  read,  and  once  even  to  recog- 
nize individuals.  The  explanation  of  this  condition  is  undoubtedly 
due  to  changes  in  the  water  balance  of  the  body  and  the  disappear- 
ance of  sugar.  These  incidentally  involve  the  lens,  causing  refractive 
changes.  I  have  always  been  able  to  reassure  such  patients  with 
the  statement  that  the  return  of  their  former  eyesight  and  even 
an  improvement  in  the  same  would  eventually  take  place.  It  is 
remarkable  to  how  great  an  extent  the  eyesight  may  return  in  a 
long-standing  but  neglected  case  of  diabetes.  Case  XV).  LSI  was 
unable  to  read  his  name  when  he  entered  the  hospital,  but  after 
three  weeks'  stay  he  was  able  to  do  so.  Case  Xo.  924  showed  marked 

1  Von  Xoorden:  Lor.  rit.,  p.  217. 


43S  TRKATMKXT 

failure  of  eyesight  on  October  2S,  11)15.  Her  eyes  were  examined 
at  this  time  by  Dr.  F.  M.  Spalding,  who  reported  a  shrinking  and 
flattening  of  the  lenses.  With  a  convex  lens  (  +  12)  in  front  of  each 
eye  the  vision  later  came  up  to  normal. 

Comparatively  few  of  my  .patients  have  had  cataracts.  The 
number  is  so  small  as  to  be  surprising,  and  it  is  probable  that 
I  have  overlooked  the  presence  of  cataract.  One  can  easily 
understand  that  Graefe  found  cataracts  in  one-fourth  of  all  his 
diabetics,  but  Frerichs,  in  400  patients,  discovered  10  cataracts, 
and  Seegen  also  reports  cataracts  present  in  4  per  cent,  of  his  series. 
One  of  my  cases,  Xo.  507,  aged  seventy-one  years,  onset  doubtful, 
after  preparatory  treatment  became  sugar-free,  and  the  cataract 
was  successfully  removed  by  Dr.  Edward  ,R.  Williams.  It  is  inter- 
esting that  the  haziness  of  the  lenses  in  beginning  cataract  may 
diminish  with  constitutional  treatment  and  improvement  of 
the  diabetes. 

One  instance  of  paralysis  of  the  abducens  muscle  1  distinctly 
recall,  though  I  cannot  identify  the  record. 

Case  Xo.  S0(>,  cited  p.  27S,  showed  a  retrobulbar  neuritis,  but  it 
was  probably  due  to  syphilis  and  not  to  diabetes. 


M.     SURGERY  AND  DIABETES. 

1.  Elements  Predisposing  to  Surgical  Failure. — Diabetic  patients 
stand  in  need  of  the  surgeon  far  more  than  normal  individuals  or 
those  suffering  from  most  other  chronic  diseases.  The  frequent 
occurrence  of  carbuncles  and  gangrene  is  the  chief  reason.  In  the 
past  the  mortality  following  surgical  interference,  whether  for  the 
relief  of  diabetic  complications  already  alluded  to  or  for  surgery 
in  general,  .was  relatively  high,  so  that  the  rule  has  been  general 
to  avoid  surgery  in  the  presence  of  diabetes  whenever  possible. 
In  the  last  few  years  the  mortality  following  surgical  operations  has 
decreased,  until  now  there  is  less  need  for  conservatism.  But  when- 
ever delay  is  not  dangerous,  the  rule  still  holds  to  defer  surgical 
interference.  It  is  surprising  how  many  apparently  severe  conditions 
clear  up  when  the  diabetes  has  been  appropriately  treated. 

If  surgery  is  indicated,  however,  diabetes  is  no  excuse  for  its  non- 
performance.  On  March  17.  1017,  a  stone  was  removed  from  the 
common  duct  of  an  old  man,  Case  Xo.  007  (Table  100)  by  Jones, 
and  a  large1  abscess  of  the  upper  lobe  of  the  right  lung  of  Case  Xo. 
ll'.'iO  ('Table  101 )  drained  by  Scudder  following  a  resection  of  portions 
of  three  ribs.  Chute  has  removed  the  prostate  from  4  diabetic 
patients  without  a  fatality,  Hubbard  has  performed  two  Cesarean 
sections  and  extensive  repair  operations  successfully,  and  Lund,  as 


SURGERY  AND  DIABETES  439 

long  ago  as  February,  1908,  removed  a  large  fibroid1  without  any 
complications,  and  has  since  obviated  the  necessity  of  as  many 
amputations  for  gangrene  as  he  has  successfully  performed  such  upon 
others  of  my  diabetics. 

Before  undertaking  an  operation  upon  a  diabetic  patient  the 
surgeon  should  thoroughly  understand  the  dangers  with  which 
the  patient  has  to  contend  and  the  elements  which  favor  surgical 
success.  The  dangers  are  four:  acid  intoxication,  slow  healing  of 
wounds,  exhaustion  and  lack  of  exercise. 

(a)  Acid  Intoxication. — Diabetic  coma  has  been  elsewhere  dis- 
cussed, and  its  prevention  will  be  taken  up  under  the  medical 
treatment  of  surgical  cases  in  what  follows. 

(6)  Slow  Healing  of  Wounds. — Statements  regarding  the  slow  heal- 
ing of  wounds  of  diabetic  patients  are  proverbial,  but  often  untrue. 
Allen  did  not  find  this  a  necessary  condition  in  his  operations  upon 
animals,  and  through  experimental  work  he  showed  that  the  presence 
of  an  excess  of  sugar  in  the  blood  was  not  deleterious.  Xo  work 
that  I  recall,  however,  has  been  done  upon  the  effect  of  an  excess  of 
j3-oxybutyric  acid  and  the  other  acid  bodies  in  the  blood.  Such 
studies  are  needed.  It  is  possible  that  the  supposed  slow  healing 
of  wounds  in  diabetic  patients  is  a  tradition  handed  down  from 
preaseptic  days  or  has  arisen  from  the  fact  that  operations  in  septic 
conditions  have  been  too  conservative,  or  finally,  that  the  frequent 
employment  of  surgery  in  old  and  debilitated  diabetics,  in  whom 
healing  even  without  diabetes  would  be  slow,  has  helped  to  make 
this  impression.  The  more  I  see  of  diabetic  surgery  the  less  differ- 
ence I  observe  in  it  from  surgery  of  the  non-diabetic. 

(c)  Exhaustion. — Too  often  in  my  experience  blame  has  been 
attached  to  the  surgeon  when  the  patient  wasted  away  after  an 
operation.  More  frequently  the  blame  should  rest  upon  the  shoul- 
ders of  the  medical  attendant.  With  better  medical  treatment 
this  element,  which  has  played  so  large  a  figure  in  the  past  in  the 
surgical  mortality  of  diabetic  patients,  should  decrease. 

(<7)  Lack  of  Exercise. — Diabetic  patients,  otherwise  properly 
treated,  thrive  upon  exercise;  deprive  them  of  it  and  they  go  down 
hill.  Pulley  weights  should  be  attached  to  the  bed;  they  should 
be  encouraged  to  move  about,  to  exercise  any  muscles  not  incapaci- 
tated; a  masseur  may  be  of  great  help,  especially  if  he  combines 
massage  with  resistant  motions. 

2.  Elements  favoring  surgical  success  are: 

(a)  Good  medical  care  before  and  after  the  operation. 

(b)  The  method  of  anesthesia. 

(c)  Employment  of  asepsis  rather  than  antisepsis. 
((/)  Avoidance  of  trauma. 

1  Joslin:    Am.  Jour.  Mcd.  Sc.,  1913,  cxlv,  p.  474. 


440  TREATMENT 

(tt)  Good  Medical  Care. — If  the  diabetic  patient  is  free  from  sugar 
and  acid  lie  requires  no  special  preparation  for  operation,  but  if  these 
products  are  present  they  should  be  removed  according  to  the  plan  of 
treatment  already  described  for  any  case  of  diabetes  (see  p.  M05).  A 
positive  ferric  chloride  reaction  is  far  more  to  be  dreaded  than  a  posi- 
tive sugar  test  both  before  as  well  as  after  an  operation.  Conse- 
quently, if  the  case  is  urgent,  even  in  the  presence  of  sugar,  operation 
may  be  undertaken  with  comparatively  little  apprehension.  If  acid  is 
also  present  a  serious  problem  is  presented,  which  must  be  solved 
for  each  individual  case.  At  present  writing  I  should  consider 
the  safest  general  rule  to  follow  the  routine  method  of  treatment 
outlined  for  cases  presenting  acidosis  and  described  on  p.  MS7. 
During  the  day  prior  to  the  operation,  the  freest  possible  adminis- 
tration of  liquids  should  be  favored.  These  should  include  broths 
on  account  of  the  salts  therein  contained,  coffee,  tea,  water,  and  if 
necessary  salt  solution  or  tap  water  by  rectum.  I  would  specifically 
advise  against  the  use  of  alcohol  at  such  a  time,  because  of  the 
possibility  of  its  upsetting  the  stomach.  This  is  of  all  things  to  be 
avoided.  If  alkalis  have  not  been  previously  given,  they  should 
not  be  begun,  but  if  the  patient  has  been  taking  sodium  bicarbonate 
in  doses  under  MO  grams  in  twenty-four  hours  omit  it;  otherwise 
decrease  the  alkali  MO  grams  a  day. 

Liquids  of  the  above  character  should  be  given  freely  up  to  as 
near  the  hour  of  operation  as  possible,  so  that  the  body  will  have  a 
full  water  content  with  which  to  excrete  acids,  which  may  form  as 
a  result  of  the  operation.  I  can  conceive  of  a  surgical  emergency 
in  which  the  patient  has  been  actually  fasted  for  a  few  days  and  yet 
acidosis  may  have  appeared  or  increased.  In  this  event  the  adminis- 
tration of  MO  grams  of  carbohydrate  in  the  form  of  the  juice  of  two 
or  three  oranges  or  45  grams  of  dry  oatmeal  or  flour,  made  into  a 
water  gruel,  might  be  of  great  help. 

The  dietetic  treatment  for  the  first  twenty-four  hours  after  the 
operation  is  fasting  save  for  the  addition  of  those'  liquids  which 
preceded  the  operation,  but  if  the  patient  is  able  to  eat,  the  same 
diet  but  in  lessened  quantities  and  without  fat  is  allowed.  One  of 
the  great  advantages  in  not  giving  the  patient  sodium  bicarbonate 
before  the  operation  is  that  it  need  not  be  repeated  after  the  opera- 
tion. A  doctor's  order  to  force  liquids  before  and  after  operation 
might  bring  disaster  by  upsetting  the  stomach,  but  this  can  be 
avoided  if  salt  solution  and  tap  water  are  administered  to  a  con- 
siderable extent  by  rectum  and  liquids  are  given  cautiously  by  the 
mouth  and  at  the  first  sign  of  need  intravenously.  It  is  a  safe  rule 
to  administer  7~>0  to  1000  c.c.  of  liquid  every  six  hours  before 
operation  to  a  patient  who  is  excreting  sugar  and  acid  and  ")()()  c.c. 
every  six  hours  to  one  who  prior  to  the  operation  has  been  made 
su<rar-  and  acid-free. 


SURGERY  AND   DIABETES  441 

The  next  day  after  the  operation,  if  the  urine  is  sugar-free,  the 
patient  is  gradually  returned  to  his  former  diet,  minus  fat,  being 
at  the  same  time  careful  not  to  exceed  his  known  tolerance  for 
carbohydrate,  and  in  the  subsequent  days,  if  sugar  and  acid  con- 
tinue absent,  the  patient's  customary  dietetic  habits  are  resumed. 
On  the  other  hand,  if  sugar  appears  after  the  operation  when  it 
was  not  present  before,  it  may  be  disregarded  for  several  days 
because  it  may  disappear  of  itself.  (See  Tables  Nos.  190,  191,  192. 
Cases  Xos.  34X,  097,  1239).  Should  this  not  occur,  routine  treatment 
of  the  diabetes  should  be  instituted. 

Patients  with  severe  diabetes  or  elderly  patients  should  be  sub- 
jected to  very  slight  dietetic  changes  preceding  operation.  Unsuc- 
cessful results  in  the  past  have  been  caused  in  large  part  by  these 
unfortunate  individuals  having  been  suddenly  placed  upon  a  strict 
protein-fat  diet,  to  which  they  were  not  accustomed.  In  consequence 
the  digestion  was  upset  quite  as  much  as  would  have  been  the  case 
with  a  normal  individual,  and  they  developed  acidosis  as  well.  The 
fasting,  incidental  to  a  routine  surgical  preparation,  predisposes  to 
acidosis  in  a  non-diabetic,  and  may  still  more  in  a  mild  or  moder- 
ately severe  diabetic  patient  unless  previously  accustomed  to  it.1 
Formerly  severe  diabetic  patients  were  filled  with  sodium  bicarbon- 
ate; this  markedly  influenced  the  fluid  content  of  the  body  and 
often  resulted  in  the  release  of  so  much  acid  as  to  overwhelm  the 
kidneys,  with  resulting  suppression  of  urine. 

(/;)  Anesthesia. — Every  effort  should  be  made  to  shorten  the 
period  of  anesthesia  no  matter  what  the  anesthetic,  and  to  avoid 
apprehension  and  excitement  on  the  part  of  the  patient.  Chloro- 
form is  absolutely  contra-indicated.  Ether  has  many  times  been 
used  with  success,  but  it  is  often  dangerous,  and  1  believe  the  state- 
ment made  upon  p.  70  will  bear  repetition — namely,  that  ether 
anesthesia  is  a  burden  which  a  light  case  of  diabetes  may  easily 
bear,  which  may  change  a  moderate  to  a  severe  case,  and  to  a  severe 
case  prove  fatal.  Nitrous  oxide  or  nitrous  oxide  and  oxygen  appear 
to  be  the  best  general  anesthetics,  provided  they  are  administered 
by  an  anesthetist  trained  in  their  use.  Postoperative  acidosis  in 
children  is  said  less  likely  to  follow  nitrous  oxide  anesthesia  than 
ether,  and  if  it  does  occur  is  less  apt  to  be  severe. 

Spinal  anesthesia  has  been  satisfactory  in  several  of  my  cases, 
though  often  undesirable  because  of  the  nervous  tension  to  which  it 
subjected  the  patient.  Local  anesthesia  with  novocain  is  the  safest 
mode  of  anesthesia,  but  it  should  be  delicately  employed  for  fear  of 
trauma  to  the  susceptible  tissues.  In  illustration  of  the  above  I 
would  cite  the  charts  of  four  cases: 

1  Bradncr  and  Reimunn:    Jour.  Am.  Mod.  Assn.,  1015,  p.  1947. 


442  TREATMENT 

Case  Xo.  34S,  male;  age  at  onset  forty-two  years;  operation  for 
removal  of  the  prostate  at  forty-nine,  seven  years  later;  spinal 
anesthesia  appeared  contra-indicated  and  light  etherization  was 
employed.  It  will  be  seen  that  a  positive  carbohydrate  balance  of 
20  grams  before  the  operation  changed  to  a  negative  carbohydrate 
balance  of  33  grams  after  operation,  and  that  the  acidosis  was 
extreme  after  the  operation,  if  the  fasting  condition  of  the  patient 
is  considered.  The  patient  fortunately  made  an  uninterrupted 
recovery  and  is  now  well  and  active.  (See  Table  190  and  also  page 
434.) 

TABLE  190. — CHART  OF  CASE  Xo.  348.     MODERATELY  SEVEKK  DIAHETES. 
REMOVAL  OF  PROSTATE. 

Urine.  Diet. 


Carbo 

Sodium 

Total 

Carbo- 

Pro- 

hydrat 

e         bicar- 

Diaeetic          Nils 

suKar, 

hydrate, 

tein,           Fat, 

balanr 

e,      bonate, 

Date. 

acid.              K'ns 

Kins. 

Kins. 

Kins.          Kins. 

Kins. 

Kins. 

1910 

July  21     . 

.        .           0 

160 

1915 

July    9     . 

.        .           0 

0 

15 

+45 

11-12 

.        .           0 

0 

20 

30            50 

+  20 

0 

July  11 

,  operation  —  removal 

of  prostate;  I  )r.  A. 

L.  C'hute;  anesthetic, 

ether. 

July  12-13 

+  + 

37 

0 

0              0 

'.)  — 

0 

13-14 

+  + 

33 

0 

0              0 

-33 

0 

14-15 

.       .    +  +  +          3.3 

11 

()' 

0              0 

-11 

0 

15-  Hi 

.     +  +  +          3.2 

30 

5 

0              0 

-31 

s 

A  uit.    1-  2 

.       .          0 

0 

TABLE 

191.—  CHART  CASE 

Xo.   097 

.     MILD 

DIABETES. 

GALL-STONES. 

(.See  p. 

443.) 

Carbo- 

Carl).,- 

Sodium 

Diaeetic 

1  ririe, 
total  siiKar, 

hydrat  e 
in  diet, 

n\  (II  ate 
balance, 

bicar- 
bonate, 

Date. 

acid. 

K'ns. 

gms. 

Kins. 

Kins. 

1914 

Feb.      2  .  .      .         0  .  .  «>.Sr;  ) 

17-18   ...          0  .  . 

18-19    .       .       .        + 
February  IS,  operation  for  gall-stone 


0 

105 

+  105 

,8 

35 

8 

-  27 

12 

Dr.  D.  F. 

Jones; 

anesthetic, 

ether. 

105 

60 

-  45 

18 

110 

34 

—  75 

0 

101 

So 

-  20 

X 

71 

110 

+  10 

0 

55 

175 

+  120 

0 

19 

110 

+  90 

0 

0 

120 

+  115 

0 

11 

120 

+  110 

0 

0 

120 

+  120 

0 

0 

95 

+  95 

0 

I                 35  +31  0 

0.x                    1                 no  +   l«)  () 

Mar.  17,  operation  for  removal  of  trail-stone   from  common  duct;   Dr.  D.  F.  Jones; 
anesthetic,  ^as  and  oxygen,  with  15  c.c.  ether. 

Mar.  17    is   ...         +                    1.9                 15                 20  +      f>  0 

is    19    .       .       .          0                    1.9                 13                 11  2  0 

19   20    ...          0                    2.2                 25                 11  +    10  0 

25   20    .              .         0                                             0                 71  +   71  0 


SURGERY  A\D  DIABETES 


443 


(  ase  No.  097,  male;  age  at  onset  forty-nine  years;  age  at  opera- 
tion for  gall-stones,  fifty-five;  anesthetic-,  ether.  The  tolerance  on 
the  day  before  operation  was  approximately  lOo  grains;  on  the  day 
of  the  operation  the  quantity  of  sugar  in  the  urine  was  3o  grams, 
and  carbohydrate  in  the  diet  S  grams,  and  a  minus  balance  con- 
tinued for  three  days  more.  The  patient  completely  recovered  and 
remained  well  and  active  until  the  end  of  191(1,  when  he  had  a 
recurrence  of  symptoms.  A  stone  was  then  removed  from  the 
common  duct  by  I).  F.  Jones.  Anesthetic,  gas  and  oxygen  and 
45  c.c.  ether  administered  by  Freeman  Allen.  Table  191,  p.  442. 


TABLE  192.— CHART  OF  CASK  1239.     ABSCESS  OF  Luxe;.     PAGE  444. 


Am- 

Total 

Diet  in 

grams. 

Blood        Blood      Alveolar 

Date, 
1017. 

Diaeetie    nioma, 
arid.         total 
gins. 

sugar 
in 
urine. 

Carbo- 
hydrate 

Pro- 
.    tein. 

Fat. 

C'Oi>,         sugar,      air  ('(  )?, 
Alco-    mm.  Hg.  per  cent.  mm.  Hg. 
hoi. 

Feb.  17  Spec 

+  +  + 

Feb.    17-18 

+  +  + 

21 

37 

18-19 

+  +  + 

31 

45 

's 

'6 

0             ..             0.17 

19-20 

H  —  h 

19 

25 

5 

0 

(I 

20-2  1 

+  +  +  +      2.4 

4 

10 

5 

0 

0 

21-22 

+  +f+      2.7 

0 

0 

0 

0 

0          47.7          0.14            ;|;j 

22-23 

-r  +  +        2.8 

2 

10 

5 

0 

0 

23-24 

+  +  +        2.6 

2 

0 

24 

0 

0             .  .               .  .               37 

24-25 

H  —  h 

3 

0 

GO 

0 

15 

25-26 

+  +  +        ''1 

8 

0 

92 

12 

30            .  .               .  .               38 

26-27 

l.Q 

7 

0 

68 

24 

15 

27-28 

6 

5 

72 

41 

30 

28-   1 

1.7 

0 

10 

70 

42 

30 

Mar.     1-  2 

+  +          1.4 

2 

15 

70 

61 

30 

2-  3 

0 

10 

70 

00 

30 

3-  4 

4-  4/- 

0 

10 

70 

81 

30          54.0           0.14 

4-  5 

1.3 

0 

10 

81 

82 

30 

5-  0 

+  +          1.3 

0 

10 

81 

88 

30 

0-  7 

+  +  + 

1 

15 

84 

88 

30 

7-  8 

+  +           1.2 

3 

20 

84 

82 

30            .  .               .  .               30 

S-  9 

+            1.0 

0 

15 

56 

21 

30 

9-10 

4- 

0 

10 

51 

1 

30 

10-11 

sl.  + 

0 

24 

77 

40 

30 

11-12 

1.0 

0 

10 

00 

43 

30 

12-13 

-j- 

3 

24 

82 

01 

30 

13-14 

+  +           1.4 

4 

20 

70 

00 

30          47.7          0.18 

14-15 

+  +  +         1.5 

4 

25 

47 

30 

30             .  .               .  .               35 

15-16 

+  +  +         1.6 

8 

37 

46 

12 

30 

16-17 

v.  si.   +        1.1 

7 

40 

OS 

13 

30             .  .               .  .               38 

17-18 

4-             0.7 

20 

75 

33 

12 

0                              .  .               35 

Operation:     Dr. 

C.  I.. 

Scudder 

.        An 

•sthetir 

:    Gas.   and  oxygen. 

18-19 

+            1.0 

23 

50 

58 

20 

30         ..           ..       {   :]!> 

19-20 

1.5 

25 

44 

58 

40 

30 

20-21 

1  .5 

9 

34 

56 

40 

21 

21-22 

1.3 

7 

34 

56 

59 

30 

22-23 

+ 

6 

34 

63 

75 

30 

23-24 

1.1 

3 

34 

56 

09 

30 

24-25 

. 

2 

34 

63 

85 

30 

25-26 

0 

6 

39 

63 

85 

30 

26-27 

1.0 

2 

29 

63 

85 

30 

27-28 

4^ 

2 

29 

06 

03 

30 

28-20 

0.8 

2 

20 

66 

03 

30 

29-30 

+ 

2 

31 

68 

01) 

30 

30-31 

4^ 

0 

37 

60 

88 

30 

April    2-  3 

0               .  '. 

0 

40 

74 

03 

May 

Sinus 

healed. 

Weight  at  entrance,  133j  pounds;  weight  March  10,  131  \  pounds;  no  alkalis  given 


444  TREATMENT 

An  abscess  in  the  upper  lobe  of  the  right  lung  was  successfully 
drained  by  (\  L.  Seudder.  The  patient,  Case  No.  12.'W,  first  pre- 
sented symptoms  of  diabetes  in  September,  191(>,  at  the  age  of 
forty-six  years,  and  three  months  later  the  disease  was  diagnosed. 
During  January,  1917,  pulmonary  symptoms  developed  and  in 
February,  when  he  first  came  under  my  observation,  after  consul- 
tation with  his  physician  and  F.  T.  Lord,  it  was  decided  to  treat  the 
diabetes  actively  and  the  abscess  of  the  lung  expectantly  for  three 
weeks,  and  then  operate  if  the  pulmonary  condition  did  not  improve. 
From  Table  192  it  will  be  seen  that  the  acidosis  (diacetic  acid  and 
ammonia)  was  severe,  though  this  was  not  revealed  by  the  (X)2 
tension  of  the  alveolar  air  or  by  the  blood,  presumably  on  account 
of  the  pulmonary  complication.  The  acidosis  was  gradually,  but 
not  entirely,  overcome.  When  it  was  seen  that  improvement  did 
not  take  place  the  patient  was  operated  upon  by  Dr.  (\  L.  Seudder 
under  gas-and-oxygen  anesthesia  through  a  rectangular  incision.  A 
large  abscess  of  the  right  upper  lobe  was  evacuated  after  removal 
of  two  inches  of  the  fourth,  fifth,  and  sixth  ribs.  The  cavity  was 
large,  receiving  into  its  interior  one  large  gauze  sponge.  Prior  to  the 
operation  fat  was  decreased  in  the  diet  and  the  carbohydrate  in- 
creased. The  highest  tolerance  for  carbohydrate  reached  in  the 
three  weeks  prior  to  the  operation  was  19  grams,  but  now,  May  14, 
it  amounts  to  over  S5  grams  and  the  wound  has  closed. 

TAHLE   10:!.  —  CHAUT  CASK  Xo.  173.     MILD  DIABETES.     ONSET  AT  SIXTY-FIVE 
YEARS;  OPERATION  AT  SEVENTY-THKEE  VEAKS.     LAPAK  JTOMY.    PACE  44,5. 

Urino,  Total  car- 

lota!  bohydrates  Sodium          Oarbo- 

Diacctic         su«ar,  in  did,  Incur-           hydrate 

Date.                                                           acid.           KHuns.  Knm'*-  bonate.        balance. 
1!)07 

Nov.     4    ........      0                 47  .  .                    0 

I'.IOS 

Feb.    10   ........      0  0  170  0  170 

1913 
X<,v.  14    ........      0  0  55  .  .  55 

1015 

Feb.  is  ........    o  o  100  o  100 

Oct.    25    ........      0  0  100  0  100 

25   2(1    .  .....      0  0  .  .  0 

2<i  27    ..  ....()  0  0  0  0 


Oct.   27  2s  .......     o  o  ::i  o  :<i 

l>s  2<»    .......      0  0  IT  0  47 

20  m  .......    o  o  <;5  o  05 

1910 

May      1  ........      (I  0  .  .  0 

1017 

Jan.     1C,  ........      0  (1.2r,')  ..  0 

See  also  tables  191  and  l'J5. 


SURGERY  AND  DIABETES  445 

Case  No.  173,  female;  age  at  onset  sixty-five  years,  age  at 
operation  seventy-three;  blood-pressure,  210.  The  operation  con- 
sisted of  a  laparotomy  for  a  complete  procidentia,  and  perineal 
repair,  which  had  seriously  incapacitated  the  patient.  Tolerance 
for  carbohydrate  before  operation  was  approximately  100  grams; 
anesthetic,  nitrous  oxide,  oxygen  and  5  per  cent,  ether.  It  will  be 
seen  that  neither  sugar  nor  acid  appeared  after  the  operation. 
Successful  convalescence  until  the  nineteenth  day,  when  a  cerebral 
hemorrhage  occurred.  Fortunately  recovery  was  nearly  complete. 
(See  Table  193.) 

(c)  The  introduction  of  aseptic  methods  accounts  for  many  im- 
proved results  in  diabetic  surgery.  Minor  surgical  ailments,  which 
were  formerly  treated  with  strong  solutions  of  corrosive  sublimate 
and  hydrogen  peroxide  later  required  major  operations.  Weak  anti- 
septic solutions  only  should  be  employed.  (Compare  the  treatment 
described  under  Gangrene,  p.  426). 

(<7)  The  avoidance  -  of  trauma  during  operations  is  universally 
advocated,  but  this  is  especially  to  be  borne  in  mind  in  diabetic 
surgery.  The  greatest  care  should  be  taken  in  handling  the  tissues. 
Skilful,  delicate  surgery  has  happy  results  in  diabetes.  Guard 
against  a  too  free  use  of  infiltration  anesthesia. 

3.  Results. — Omitting  operations  for  gangrene  and  carbuncle,  dis- 
cussed elsewhere,  surgeons  have  performed  the  following  34  major 
operations  upon  my  series  of  cases,  with  seven  deaths : 

TABLE  194. — SURGICAL  OPERATIONS  UPON*  DIABETIC  PATIENTS. 

Total  number  Results. 

Operation.  of  cases.          Successful.  Fatal. 

Gall-stones 4  4  0 

Appendicitis 5  2  3 

Cancer: 

breast 2  2 

bladder 3  1  21 

uterus 1  1 

Prostate 5  5  0 

Fibroid 5  4  1 

Extensive  perineal  repairs 3  3  0 

Exploratory  laparotomy 1  1  0 

Amputation  of  leg  for  septic  knee     ...  1  1  0 

Mastoid 2  2  0 

Abscess  lung 1  1  0 

Drainage  bladder 1  0  1 

Total 34  27  7 

In  Table  105  I  have  grouped  27  cases  who  were  operated  upon  and 
under  my  care  shortly  before  or  after  operation.  There  were  but 
five  deaths,  two  had  cancer,  one  gall-stones,  one  pernicious  anemia 

1  One  death  was  due  to  metastases  and  the  other  to  pulmonary  embolism. 


440 


TREATMENT 


and  another  a  severe  anemia.  All  patients  who  died  were  given 
ether,  but  the  number  of  cases  is  too  small  to  warrant  far-reaching 
conclusions,  for  there  were  inanv  who  took  ether  and  lived. 


TABLE  19.5. — Sumac 
MY  CARE 


AL    OPERATION'S    UPON    DlABKTIC    P.\TIKNTS    UNDER 

SHORTLY  HKFORK  OH  .A  FT  Kit  OPERATION. 

Results. 


Operation.                       Total  cases.                       Anesthetic.                          cases 

'  Ether        

<>97 

Gas    and    oxygen,   with 

Gull-stones        .... 

4 

45  c.c.  ether 

(J971 

Ether        

Ether        

'Ether        

2'.) 

Appendicitis     .... 

3 

Ether 

'J4S 

Ether 

(  'ancer  of  uterus    . 

.      1                  Ether        

799 

Cancer  of  breast. 

1                   Gas     and     oxygen     and 

ether     

IONS 

Cancer  of  bladder 

.      1                  Ether        

49S 

Cancer  of  bladder 

.      1                  Ether        .       .    %.       .      . 

57(i 

Cancer  of  bladder 

.      1                  Ether        .       .    *.       .       . 

Ether        

348 

Spinal  anest  hesia 

559 

Prostate       

.      5 

Gas  and  oxygen 

599 

Spinal  anesthesia 

833 

Spinal  anesthesia 

10S(> 

Drainage  of  bladder    . 

1                  Novocain       .... 

1042 

Ether        

120 

Fibroid         

.     3 

Ether        

127 

Nitrous  oxide 

Ether        

60 

Extensive  perineal  repairs 

3 

Nitrous    oxide,     oxygen 
and  ether  sequence     . 

173 

Ether 

'{()S 

Exploratory  laparotomy  . 

1                  Ether        

:5:5:{ 

Abscess  of  lung 

1                   Gas  and  oxygen 

12:;<) 

Mastoid 

1                  Ether 

503 

Fatal 
cases. 


G393 


8554 


9395 


7216 


Appendicitis.—  It  will  be  seen  that  three  patients  with  appendicitis 
died.  (Table  194,  p.  445.)  The  details  follow:  Case  No.  5;5o  was 
taken  with  acute  appendicitis  twenty-four  hours  away  from  his 
home,  refused  to  go  to  a  hospital  and  when  he  reached  the  surgeon, 
who  operated  upon  him  at  once,  "there  was  a  quart  of  pus  in  the 
peritoneal  cavity  and  thrombosis  of  many  of  the  mesenteric  veins." 
Case  No.  54:2  was  taken  very  ill  with  acute  appendicitis  upon  a 
fishing  trip  and  operated  upon  two  days  later,  but  died  at  the  end  of 
a  week  in  coma.  Case  No.  S55  is  already  reported  under  Cases 
Unsuccessfully  Treated  by  Fasting,  p.  o50. 

1  Two  years  after  fir>t  operation,  stone  removed  from  common  duct. 

2  Complicated  with  severe  pernicious  anemia. 

3  Gall-stones,  coma.      Today  an  avoidable  death. 

4  Seen  only  once,  four  days  after  operation. 
•''  Died  of  pulmonary  embolism. 

6  Complicated  with  severe  anemia. 


SURGERY  AXD  DIABETES  447 

Removal  of  Uterine  Fibroids. — Case  No.  721  died  after  operation 
for  removal  of  fibroid  of  uterus;  age  at  onset  forty-five  years; 
age  at  operation,  forty-nine;  extreme  pallor — in  fact  operation 
was  forced  because  of  repeated  hemorrhages.  On  entrance  to 
hospital  April  21,  1914,  sugar  was  3  per  cent.,  diacetic  acid  present. 
At  that  time  I  did  not  employ  fasting  treatment,  but  the  patient 
became  sugar-free  on  May  7,  with  a  tolerance  for  15  grains  carbo- 
hydrate. Shortly  after  she  grew  worse,  acidosis  reappeared.  The 
initial  condition  of  the  patient,  however,  demanded  operation. 
This  was  performed  (anesthetic,  nitrous  oxide)  and  she  succumbed 
forty-eight  hours  after  operation.  Today,  with  fasting  treatment, 
transfusion  and  the  use  of  gas  and  oxygen,  it  is  possible  that  the 
patient  might  have  been  saved,  but  her  condition  was  extremely 
grave  apart  from  the  diabetes.  Case  Xo.  127  is  interesting  as  being 
the  only  one  of  my  diabetic  series  in  which  sugar  disappeared  after 
the  fibroid  was  removed.  Age  at  onset,  thirty -nine  years;  age  at 
time  of  operation,  forty-seven;  following  the  operation,  which  was 
in  the  year  1900,  there  was  marked  suppuration  of  so  extensive  a 
character  that  drainage  was  established  through  the  abdomen,  the 
vagina  and  rectum.  The  patient  at  length  recovered  and  nine  years 
after  operation  was  in  good  health  and  I  thought  the  sugar  had 
disappeared  permanently,  but  on  April  25,  191(>,  which  was  ten  years 
after  the  operation  I  was  fortunate  enough  to  secure  a  specimen  of 
this  patient's  urine  and  it  contained  104  grams.  May,  1917.  Urine, 
0.7  per  cent,  sugar.  Blood  sugar,  0.22  per  cent.  Non-protein 
nitrogen,  34  mg.  per  100  c.c. 

Removal  of  Prostate. — The  5  cases  operated  upon  recovered, 
though  1  died  later  of  cancer  of  the  stomach.  Case  Xo.  34S  caused 
considerable  apprehension  after  the  operation  because  of  the 
development  of  acidosis,  undoubtedly  due  to  the  use  of  ether  as  an 
anesthetic.  This  case  is  reported  in  detail  on  page  339.  Case  Xo. 
833,  with  onset  at  sixty-eight,  was  a  mild  diabetic  and  sugar-free 
at  the  time  of  the  operation.  His  weight  had  fallen  from  249  pounds 
to  1(>5  pounds.  Spinal  anesthesia  was  used.  Case  Xo.  599,  with 
onset  of  diabetes  at  the  age  of  sixty-two  years,  was  operated  upon 
two  years  later,  April,  1915.  Anesthetic,  gas  and  oxygen.  Case 
X"o.  559,  with  onset  of  diabetes  at  seventy-three  years,  was  operated 
upon  at  seventy-four  years,  January  14,  1913.  Spinal  anesthesia 
was  employed.  X'one  of  these  cases  have  shown  the  remarkable 
increase  in  tolerance  for  carbohydrate  following  the  operation  which 
has  sometimes  been  observed  by  others  and  I  remember  to  have 
seen  reported. 

Strouse1  states  that  of  38  operations  upon  diabetics  in  the  last 
fifteen  years  at  the  Michael  Reese  Hospital,  there  have  been  31.3 

'  Strouse:  Chicago  Clinics,  April  19 16,  p.  37. 


448  TREATMENT 

per  cent,  deaths,  but  there  were  no  deaths  among  8  patients  who 
were  properly  prepared  for  operation.  By  properly  prepared  he 
evidently  means  made  sugar-  and  acid-free  and  for  a  few  days 
before  operation  given  alkalis. 

Karewski1  reported  225  operations  with  a  mortality  of  21  per  cent. 

Fischer2  had  a  total  mortality  of  4S.S  per  cent,  with  SO  diabetic 
patients  and  72.7  per  cent,  in  the  11  operations  for  diabetic 
gangrene. 

Karewski3  reports  that  11.$  per  cent,  of  68  diabetic  patients  died 
of  coma  after  operations  on  aseptic  tissues,  and  21.7  per  cent,  of 
69  cases  after  operations  on  infected  tissues.  Berkman4  reports 
2  deaths  among  26  cases  at  the  Mayo  Clinic  during  1915. 

N.     PREGNANCY  AND  DIABETES. 

A  small  quantity  of  sugar  in  the  urine  during  pregnancy  is  so 
common  an  occurrence  as  to  attract  comparatively  little  attention, 
and  the  frequency  with  which  it  is  met  probably  depends  upon  how 
often  it  is  sought. 

According  to  Guelmuyden8  glycosuria  develops  in  10  to  12  per 
cent,  of  all  pregnancies  and  some  have  encountered  it  in  40  per  cent. 
As  a  rule  in  such  cases  the  sugar  permanently  disappears  soon 
after  confinement,  although  it  may  recur  with  succeeding  preg- 
nancies, and  ultimately  a  severe  form  of  diabetes  may  develop. 
Such  an  eventuality  is  cited  by  Foster:  ".  .  .  there  had  been 
a  pronounced  glycosuria  during  two  pregnancies  which  had  entirely 
subsided  after  the  birth  of  each  child  so  that  there  was  no  sugar  in 
the  urine,  and  no  dietetic  restriction  was  employed.  During  the 
third  pregnancy  there  was  observed  not  only  glycosuria,  but  also 
a  moderate  increase  of  thirst  and  following  the  termination  of  this 
pregnancy  the  sugar  excretion  and  the  symptoms  persisted."0 
Case  Xo.  o()9  showed  sugar  in  1X97  during  pregnancy,  but  following 
confinement,  with  resulting  dead  baby,  it  disappeared,  but  returned 
in  nine  years  in  the  form  of  moderate  to  severe  diabetes.  The 
association  of  this  case  with  gall-stones  and  with  involuntary  fasting 
is  described  on  p.  295. 

With  our  present  knowledge  it  is  quite  possible  that  such  an 
outcome  could  be  prevented  by  active  treatment  of  the  glycosuria 
from  the  very  start.  Ten  cases  of  pregnancy  in  which  the  patients 
showed  small  quantities  of  sugar  have  occurred  in  my  series.  In 

1  Karewski:   ('ited  by  St rouse. 

'-'  Fischer:    Drutsrh.  Ztsrhr.  f.  Therapie,  1014,  rxxxi,  p.  40. 

:i  Karewski:    Deutsch.  med.  Wrhnsrlir.,  1914,  xl,  p.   S. 

4  Berkman:   .Journal-Lancet,  1910,  xxxvi,  p.  .'->09. 

s  Guelmuyden:  Jour.  Am.  Med.  Assn.,  1914,  Ixiii,  p.  1798. 

e  Foster:    Diabetes.  Mellitus,  Lippiucott,  1915,  p.  99. 


PRKGXANCY  AND  DIABETES  449 

2  of  these  cases  (Cases  Xos.  G98  and  318)  the  sugar  was  found 
before  conception  took  place,  but  in  all  it  was  moderate  throughout. 
Among  these  10  cases  there  were  fourteen  pregnancies  and  eleven 
children,  and  both  mothers  and  children  are  well.  It  is  not  strange 
that  4  of  the  cases  occurred  in  physicians'  families.  (For  a  complete 
report  of  7  of  these  cases,  see  Boston  Med.  and  8urg.  Jour.,  1915, 
clxxiii,  p.  841.)  Case  No.  309  is  described  above  and  Cases  Xos. 
791  and  1017  were  primipanv  and  delivered  of  healthy  children. 

1.  Cases  of  Pregnancy  Showing  Large  Quantities  of  Sugar. — The 
gloomy  outlook  for  pregnant  women  showing  large  quantities  of 
sugar  became  somewhat  modified  when  it  was  recognized  that 
these  cases  could  be  divided  into  two  groups,  based  on  the  appear- 
ance of  sugar  before  or  after  pregnancy  began.  If  pregnancy 
occurred  in  diabetic  patients  the  outlook  was  considered  far  more 
serious  than  when  diabetes  first  appeared  during  pregnancy.  A 
somewhat  more  hopeful  view  of  the  whole  situation  was  taken  by 
Eshner,1  and  by  Stengel,2  and  still  more  recently  by  Xeuman,3  who 
reported  G  successful  cases. 

It  is  not  surprising  that  so  little  progress  was  made  in  the  treat- 
ment of  pregnant  women  with  diabetes,  because  progress  in  the 
treatment  of  uncomplicated  diabetes  has  been  slow.  However, 
the  introduction  of  the  therapeutic  methods  of  Naunyn  and  von 
Noorden  started  an  improvement,  and  a  considerable  number 
of  pregnant  women  with  sugar  in  the  urine  have  now  been  sub- 
jected to  the  same  kind  of  rational  treatment  which  is  employed 
in  ordinary  cases  of  diabetes.  But  it  is  only  fair  to  say  that  the 
general  practitioner  still  has  a  horror  at  the  discovery  of  a  con- 
siderable quantity  of  sugar  in  the  urine  during  pregnancy.  For 
this  reason  I  shall  record  in  some  detail  Case  No.  S12,  in  which 
diabetes  of  moderate  severity  occurring  during  pregnancy  was 
successfully  treated,  but  for  the  detailed  records  of  G  other  cases 
would  refer  to  the  Boston  Mcd.  and  Surg.  Jour.,  1915,  clxxiii, 
p.  841.  Another  case  of  diabetes  (Case  Xo.  729),  of  eight  years' 
duration,  in  which  the  tolerance  for  carbohydrate  during  the  first 
seven  months  of  pregnancy  rose  from  15  to  75  grams,  is  here  reported 
for  the  first  time,  and  Case  Xo.  1070,  with  severe  diabetes,  alveolar 
CO2,  20  mm.  Hg,  is  described  as  well.  Before  entering  upon  a  dis- 
cussion of  these  cases,  a  summary  of  5  other  cases,  not  hitherto 
reported,  will  be  recorded.  Case  Xo.  102  had  four  pregnancies  and 
two  healthy  children  during  the  course  of  her  twenty-two  years  of 
diabetes,  and  Case  X\>.  1018  had  four  babies  and  one  miscarriage  in 
ten  years  and  is  now  in  good  condition.  Case  X'o.  729  (see  p.  431) 

:  Eshnor:  Am.  Jour.  Mod.  Sc.,  1907,  cxxxiv,  p.  375. 
2  Stengel:  Pcnna.  Med.  Jour.,  1907-S.  ii,  p.  900. 
3Xeunv.m:  /tschr.  f.  -irtzl.  Fortbild,  1913,  x,  p.  307. 

29 


450  T  RE  ATM  EXT 

had  two  pregnancies  with  healthy  children  and  two  miscarriages 
during  the  course  of  her  diabetes  and  finally  succumbed  to  ether 
anesthesia.  Cases  Xos.  4o9  and  401  died  within  one  year  of  the 
onset  of  the  diabetes,  though  death  was  unconnected  with  the 
abortions  which  I  understand  were  performed. 

Case  Xo.  S12,  a  physician's  wife,  first  seen  December  29,  1914. 
The  examination  of  the  urine  showed  no  albumin,  sugar  0.4  per 
cent.,  no  diacetic  acid.  Xo  diabetic-  heredity  existed.  The  patient 
had  had  measles,  whooping-cough,  and  a  rather  peculiar  case  of 
typhoid.  Married  at  twenty-one;  one  year  later  a  stillborn  child. 
In  .June,  191  \,  she  became  pregnant,  and  in  Dec-ember,  1914,  during 
the  sixtltmonth  of  pregnancy,  sugar  was  found  in  the  urine.  It  was 
impossible  to  determine  when  it  first  appeared. 

The  patient  felt  well  except  for  slight  dyspnea;  polydipsia  and 
moderate  polyuria  existed,  but  the  appetite  was  decreased  rather 
than  increased;  the  highest  weight  was  179,  and  the  present  weight 
1()9  pounds;  normal  reflexes;  heart  normal;  pulse,  100;  blood- 
pressure,  l.'H);  considerable  edema  of  the  lower  extremities,  espe- 
cially the  right  leg,  and  an  abdomen  consistent  with  a  pregnancy  of 
six  months. 

The  case  appeared  to  me  most  favorable  to  attempt  to  carry 
through  to  term.  The  patient  had  previously  been  fat.  The 
polyuria  was  not  great,  although  the  percentage  of  sugar  was  high. 
During  the  week  intervening  between  the  first  visit  and  the  entrance 
of  the  patient  to  the  hospital  no  alteration  in  the  diet  was  made 
(Table  19(1,  p.  45o),  and  from  it  will  be  seen  that  the  percentage 
of  sugar  underwent  no  change. 

Following  entrance  the  carbohydrate  in  the  diet  was  gradually 
decreased  from  approximately  loO  grams  to  45  grams,  and  the 
patient  was  allowed  a  very  moderate  quantity  of  protein  and  fat- 
Sugar  then  disappeared,  but  the  diacetic  acid  rose  to  three  plus 
and  the  ammonia,  which  at  entrance  was  !..'•>  grams  in  twenty-four 
hours,  rose1  to  M  grams,  but  with  S  grams  of  sodium  bicarbonate 
(I  would  not  use  it  today),  a  slight  increase  in  the  carbohydrate 
and  decrease  in  fat,  the  ammonia  fell  to  normal,  where-  it  remained 
until  just  after  confinement.  The  tolerance  for  carbohydrate  rose 
to  100  grams.  The  protein  was  kept  in  the  neighborhood  of  from 
75  to  100  grams  — a  little-  over  1  gram  per  kilogram  body  weight; 
the  fat  was  only  such  as  enabled  the-  patient,  to  retain  her  weight. 
During  the  last  three  months  of  pregnancy  the  patient  was  in  as 
good  health  as  any  normal  pregnant,  woman. 

The  blood  sugar  on  February  !•>,  1915,  after  dinner,  amounted  to 
0.25  per  cent.,  and  the  urine  showed  a  trace  of  sugar  and  diacetic 
acid.  The  carbohydrate  ingested  was  110  grams.  On  February 
IS,  1915,  fasting,  but  with  the  same  quantity  of  carbohydrate  in 


PREGXAXCY  A XI)   DIABETES  451 

the  diet  the  blood  sugar  was  ().!(>  per  cent.     The  urine  showed 
a  trace  of  sugar. 

The  method  of  delivery  was  carefully  considered  by  Dr.  -I.  ('. 
Hubbard,  who  had  charge  of  the  obstetric  side  of  the  case,  and  it 
was  decided  that  a  Cesarean  section  presented  the  least  danger  to 
mother  and  child.  This  was  performed  March  24,  1915. 

Light  etherization  was  employed  for  the  operation.  It  had 
been  previously  agreed  that  if  acidosis  developed  prior  to  the  ter- 
mination of  labor,  local  anesthesia  should  be  used.  Had  gas  and 
oxygen  or  local  anesthesia  been  employed  the  acidosis  which  followed 
confinement  would  quite  likely  have  been  avoided.  (See  Case  No. 
1070,  p.  457.) 

The  blood-pressure,  which  was  130  on  December  29,  1914,  had 
remained  essentially  the  same,  and  was  125  on  the  day  before 
delivery. 

The  urine  for  the  twenty-four  hours  preceding  the  operation  was 
as  follows:  1710  c.c.;  specific  gravity  1012;  acid;  slightest  possible 
trace  of  albumin;  nitrogen  11.3  grams;  ammonia  0.9  grams;  no 
sugar.  The  diet  for  the  same  day  contained  about  120  grams  of 
carbohydrate.  During  the  twenty-four  hours  following  delivery 
a  trace  of  sugar  appeared  in  the  urine,  but  the  ammonia  remained 
at  0.8  gram  and  the  nitrogen  at  8.8  grams.  Diacetic  acid  was 
present,  and  the  sediment  showed  numerous  brown  granular  and 
a  few  hyalin  casts.  Upon  the  second  day  there  was  0.2  per  cent,  of 
sugar  by  the  Benedict  test,  but  the  urine  was  0.0  per  cent,  levorota- 
tory  on  account  of  the  acidosis,  which  was  proven  by  the  presence 
of  2.2  grams  of  ammonia  and  a  marked  diacetic  acid  reaction.  The 
sediment  showed  an  occasional  hyalin  cast.  Upon  the  third  day  the 
urine  only  showed  a  trace  of  sugar,  but  was  0.8  per  cent,  levorota- 
tory,  the  ammonia  was  1.8  grams,  and  the  nitrogen  8.7  grams. 
Upon  the  fourth  day  it  was  essentially  the  same;  there  were  no 
casts.  Thereafter  the  sugar  disappeared,  and  up  to  the  present 
time,  April,  1917,  has  never  returned  in  a  quantitative  amount. 

Upon  the  day  of  delivery  and  the  two  following  days  the  patient 
was  practically  fasted  on  account  of  the  return  of  sugar  and  diacetic 
acid.  The  diet  was  then  gradually  increased,  beginning  first  with 
a  small  amount  of  carbohydrate  and  protein,  and  the  fat  was  limited 
to  approximately  50  grams.  Within  a  week  the  diet  had  been 
brought  back  nearly  to  what,  it  was  prior  to  delivery,  and  from  this 
time  on  convalescence  was  uneventful,  and  finally  the  patient  was 
discharged  upon  a  diet  containing  82  grams  carbohydrate. 

The  baby  was  normal  in  every  way,  and  the  weight  at  birth  was 
eight  pounds,  reached  thirteen  pounds  on  July  30, 1915,  and  the  child 
has  remained  well  since.  It  is  frequently  maintained  that  diabetic- 
patients  cannot  nurse  their  babies.  Nursing  was  easily  maintained 


452 


T  RE ATM  EXT 


in  this  case  until  into  June,  when  the  milk  rather  abruptly  ceased. 
Mother  and  child  are  in  good  condition  April  3,  1017. 

TAHLE  190. — CASE  No.  812.     PREGNANCY  AND  DIABETES.     CE.SAREAN 

SECTION. 


29.191  1 

915 
o 

5-  (1 
(1-  7 

7-  S 

8-  9 
9-10 

10-11 
11-12 
12-13 
13-14 
14-15 
1(5-17 
17-18 
20-21 
22-  23 
24-25 
25  27 
27-29 
29  39 
30-31 
31-  1 

1-  2 

2-  3 
5-  (i 


Mar. 


Diaeetic 

acid. 


Tra 


Urine. 


Total 


o.4';; 
(i.-i- ; 

31 
40 
20 
Tr. 
0 
0 
0 
0 
0 
0 
0 
0 
0 
0 
(I 
0 
0 
0 
0 
0 


Carbo- 
hydrate 


Carbo- 
hydrate 
balance, 


Blood 

sunar. 


Weight. 


Mother, 


1  (  >!i~i-rvc>  decrease  of  ferric  chloride  reaction  with  elimination  of  sodium  bicarbonate, 
-Delivery   by  (Vsarean   section.      .1.   ('.    Ilubbanl.      Anesthetist,    Freeman    Allen.      Anesthetic, 
et  her.     C  )l»erve  appearance  and  persistence  of  acidosis.  alter  operation.     In  a  subsequent  operation 
upon  ('a.-c  No.  1(170,  p     157,   novocaiti  was  employed.       Albumin  at  no  t  ime  exceeded  the  slightest 
pa-.-ible  trace,   and  casts  were  never  present  in  the  sediment  except  just  after  delivery. 


PREGNANCY  AND  DIABETES  453 

Thirteen  cases  of  severe  diabetes  coexistent  with  pregnancy  have 
been  seen,  but  nine  of  these  occurred  in  former  years  when  treat- 
ment was  less  satisfactory.  Yet  under  these  conditions  occasionally 
a  patient  came  through  confinement  successfully. 

An  unfortunate  complication  has  often  been  the  appearance  of 
albumin  and  casts  shortly  before  delivery.  This  took  place  in  Case 
No.  307,  seen  in  consultation  with  Dr.  J.  G.  W.  Knowlton  in  1910. 
This  patient  survived  confinement  despite  the  appearance  of  marked 
anasarca  and  0.3  per  cent,  of  albumin,  but  the  baby  was  lost.  If 
such  a  result  could  be  attained  six  years  ago,  it  is  obvious  that 
with  the  improvement  in  treatment  of  diabetes  and  nephritis,  still 
better  results  might  now  be  obtained.  It  is  possible  that  an  early 
Cesarean  section  might  have  saved  the  child. 

A  patient  may  go  through  the  pregnancy  without  notable  symp- 
toms and  be  delivered  of  a  healthy  child.  Such  a  case  was  Case 
No.  IOC),  seen  in  consultation  with  Dr.  F.  W.  Taylor.1 

Multiple  pregnancies  may  take  place  in  the  presence  of  consider- 
able quantities  of  sugar,  and  yet  recovery  be  quite  satisfactory. 
This  happened  with  Case  No.  854,  who  was  seen  by  me  in  the  third 
month  of  her  third  pregnancy,  and  following  a  successful  confine- 
ment she  reported  on  November  17,  1915:  "  I  have  got  a  big  baby 
boy,  born  October  11,  1915.  I  am  strong  and  well." 

The  unfavorable  course  of  most  pregnant  women  has  undoubt- 
edly been  due  to  neglect  of  proper  treatment.  This  took  place  in 
Case  No.  60S,  who,  at  the  age  of  twenty-eight  years,  despite  her 
knowledge  of  the  existing  diabetes,  married  and  promptly  became 
pregnant.  As  her  father  also  had  diabetes,  there  was  a  prospect 
of  the  disease  running  a  mild  course,  and  this  was  favored  by  her 
being  placed  upon  dietetic  treatment  by  her  family  physician,  who 
had  had  considerable  experience  with  diabetes.  However,  she 
gave  up  treatment  and  put  herself  under  the  care  of  a  clairvoyant, 
and  I  saw  her  for  the  first  time  at  the  beginning  of  coma. 

A  similar  instance  is  that  of  Case  No.  (104,  also  an  hereditary 
case  of  diabetes  in  a  fat  woman.  When  first  seen,  upon  a  moderate 
diet,  the  urine  was  free  from  sugar.  However,  in  the  absence  of 
her  family  physician,  she  neglected  treatment,  and  when  the  case 
next  came  to  my  attention,  during  the  sixth  month  of  pregnancy, 
3.X  per  cent,  of  sugar  was  present  in  the  urine  and  a  slight  trace 
of  diacetic  acid,  and  soon  albumin  appeared.  In  the  following 
month,  on  account  of  urgent  symptoms,  the  pregnancy  was  ter- 
minated, and  the  patient  died  a  few  hours  later  in  coma,  probably 
uremic.  Ether  was  used.2 


1  Taylor:  Boston  Mod.  and  Surtr.  Jour.,  1S99,  rxl,  p.  205. 

2  Today  I  should  consider  ether  contra-indicated. 


454  TREATMENT 

The  advisability  of  an  abortion  is  always  raised  when  sugar  in 
considerable  quantity  is  discovered  in  pregnant  women.  In  one 
of  the  milder  eases  of  my  group  this  was  performed,  not  so  much 
on  account  of  the  sugar,  but  on  account  of  albumin  and  mental 
symptoms.  The  same  procedure  was  carried  out  in  one  of  the 
severe  cases,  that  of  Case  No.  (171,  aged  twenty-five  years,  first 
seen  November  25,  1913.  The  patient  was  a  Jewish  woman,  who 
probably  developed  diabetes  in  April,  1912,  although  unrecognized 
by  herself.  She  was  married  in  June,  1912,  and  the  disease  was 
discovered  in  August,  1912.  At  the  first  visit  the  urine  contained 
7.2  per  cent,  of  sugar.  She  was  advised  not  to  become  pregnant, 
but  pregnancy  did  take  place  in  January,  1914.  The  urine  did  not 
become  sugar-free,  and  an  abortion  was  successfully  performed  by 
Dr.  L.  V.  Friedman  in  March,  1914.  J  later  learned  that  she  again 
became  pregnant  and  in  October,  1914,  committed  suicide. 

A  review  of  the  23  cases  of  diabetes  associated  with  pregnancy 
coming  under  my  observation  gives  hope  that  in  the  future  such 
patients  will  take  a  far  more  favorable  course  than  has  been  generally 
believed.  It  is  true  that  nine  of  the  women  with  severe  diabetes 
have  died,  but  in  each  instance  some  harmful  cause  was  present 
which  today  would  be  susceptible  of  treatment.  The  favorable 
outcome  of  Cases  Xos.  XI 2,  430  (p.  454)  and  1070  (p.  457)  encourages 
one  to  believe  that  even  if  the  patient  had  a  somewhat  severer  type 
of  diabetes,  it  could  be  successfully  overcome.  Several  expedients 
not  required  in  the  treatment  of  Case  Xo.  X12  could  be  employed, 
notably:  (1)  fasting;  (2)  the  selection  of  gas  and  oxygen  in  prefer- 
ence to  ether  (of  course  chloroform  would  not  be  employed)  or  even 
local  anesthesia;  (3)  the  early  performance  of  a  Cesarean  section 
at  the  first  sign  of  unfavorable  renal  symptoms. 

2.  Conclusions  upon  Pregnancy  and  Diabetes. — From  a  study  of 
these  cases  it  would  seem  that  the  secret  of  success  in  the  treatment 
of  pregnant  women  with  sugar  in  the  urine  could  be  summarized  as 
follows: 

1 .  The  patients  should  remain  under  constant  supervision  through- 
out the  course  of  the  pregnancy  and  for  months  and  years  after  con- 
finement, because  it.  is  not  uncommon  for  the  sugar  to  return. 

2.  Treatment  should  follow  exactly  the  same  methods  which  are 
employed  in  the  treatment  of  the  usual  case  of  diabetes,  although 
especial  pains  should  be  taken  to  prevent  the  appearance  of  acidosis 
by  restriction  of  fat  in  the  diet. 

3.  Fven   when   sugar   appears   to   a    slight    extent    in   pregnant 
women,  it  should  be  carefully  watched  and  controlled  by  diet. 

4.  The  advantages   of  a   Cesarean   section   should   be  borne   in 
mind. 

5.  Ether  anesthesia  is  not  as  safe  as  gas  and  oxygen.     If  ether 


PKEGNAXCY  A XI)  DIABETES  455 

should  be  used,  as  brief  an  anesthesia  and  as  little  ether  as  possible 
should  be  employed.  Local  anesthesia  has  proven  satisfactory, 

G.  Many  statements  occurring  in  the  literature  of  pregnancy  and 
diabetes  must  be  revised.  Pregnancy  in  diabetes  does  not  demand 
immediate  abortion,  even  if  acidosis  is  present.  (See  Case.  Xo. 
1070.)  If  pregnant  diabetic  cases  are  suitably  managed,  they  will 
very  likely  abort  less  frequently.  It  cannot  yet  be  accepted  as 
proven  that  pregnancy  aggravates  a  diabetes.  It  is  quite  possible 
that  the  reason  for  a  patient  with  diabetes  becoming  worse  during 
pregnancy  is  simply  due  to  the  ingestion  of  an  unusual  quantity  of 
food.  Reliable  data  upon  the  carbohydrate  tolerance  of  diabetic 
patients  before  and  after  pregnancy  are  not  available,  although 
Maase1  records  a  single  such  instance.  Nursing  is  not  contra-indi- 
cated following  the  confinement;  the  diversion  which  it  affords  the 
patient  may  offset  the  extra  demands  thrown  upon  the  metabolism. 
Too  few  data  have  been  accumulated  regarding  the  blood  sugar  of 
pregnant  women  to  warrant  conclusions.  The  same  statement  may 
be  made  about  the  alleged  excessive  weight  of  children  of  diabetic 
mothers.  The  next  few  years  may  show  that  pregnancy  may 
take  place  in  diabetic  patients  far  more  readily  than  has  been  sup- 
posed. It  is  certainly  true  that  with  the  improvement  in  the  treat- 
ment of  diabetic  patients,  diabetic  women  will  be  less  likely  to 
avoid  pregnancy.  In  fact,  the  above  prediction  has  come  true,  but 
before  reporting  a  recent  case  I  would  call  attention  totlie  experiments 
of  Carlson  and  Ginsberg,2  which  are  interesting  rather  than  encourag- 
ing. Whereas  total  extirpation  of  the  pancreas  in  non-pregnant  dogs 
results  promptly  in  the  onset  of  pancreatic  diabetes,  complete 
pancreatectomy  in  pregnant  bitches  near  term  is  not  followed  by 
hyperglycemia  and  glycosuria  as  long  as  the  fetuses  are  alive  and 
the  placental  connections  are  not  severed.  At  the  onset  of  labor 
blood  sugar  begins  to  rise  and  characteristic  pancreatic  diabetes  is 
established  on  the  completion  of  the  delivery. 

3.  Notable  Increase  in  Tolerance  for  Carbohydrate  during  Preg- 
nancy in  a  Case  of  Diabetes  of  Seven  Years'  Duration. — Case  Xo. 
43(>  first  came  under  my  observation  August  1,  1911,  with  onset  of 
diabetes  at  the  age  of  twenty-two,  in  May,  1909,  when  S  per  cent,  of 
sugar  was  found.  The  family  history  is  remarkable  in  that  the 
mother  died  of  diabetes  at  the  age  of  fifty-five,  having  probably  had 
the  disease  ten  years,  and  five  uncles  and  aunts,  of  whom  one  is  Case 
Xo.  759,  p.  489,  have  had  the  disease.  The  past  history  was  nega- 
tive except  that  the  onset  of  the  disease  took  place  coincidentally 
with  the  death  of  the  patient's  parents.  The  patient  was  overweight, 
and  at  the  first  visit  weighed  152  pounds,  which  was  0  pounds  less 

1  Masse:  Char.  Ann.,  1910,  xxxv,  p.  :«. 

2  Carlson  and  Ginsberg:  Am.  Jour.  Physiol.,  1914,  xxxvi,  p.  217. 


TREAT  ME  XT 


than  thr  highest  weight.  Physical  examination  was  negative.  The 
course  of  the  disease  in  the  patient  is  shown  by  the  annexed  chart. 
(Table  1<)7.) 

T.VHU-:  107. — CASE  Xo.  4:>C>.     ILLTSTHATIOX  OF  RISK  ix  TOLKKAXCK  FOR 
CAKHOIIYDKATK  IHKIM;   PKKCXAXCV. 


Date. 

Ainmo- 
Vol.,           Diacetic               nia. 
c.c.               acid.                 total 
grains. 

I'rine                               Carho-          Nuked          ,., 
MWir,         Carho-        hydrate      weight  of        l!l"'"' 
total         hvdrute.       balance,       patient, 
Kraiiw.                           srams.        pounds!      "('r  <><1'lt- 

1909 

May 

sr; 

1911 

July    31 

1250               0 

45                                                152! 

1912 

Jan.       9 

1020              + 

22                                                151! 

June    11 

900              + 

2                

1913 

Mar.  22 

MO              + 

2                                   HO; 

Dec.    23 

1200            +  + 

21 

191  4 

Jan.       9 

1050            +  + 

11 

23 

1140       +  +  +  + 

0 

Mar.  2s 

750           +  + 

0 

Sept.  is 

90i)           +  + 

11                20              +    9 

Dec.      5 

1200         +  +  +           2.52 

0 

1915 

April  12 

900           ++              1.8 

0                15              +15 

Prctr  nancy  li 

••ran    Au  trust,  191  5. 

Autr.   27 

030              + 

0 

Sept.  20 

+  + 

0 

Oct.     13 

1230            ++              2.3 

0                                                   133! 

Nov.     4 

900          +  +  +            1.0 

0                                +10           133! 

21 

900          -r  +  +           2.2 

0               45              +45                             0.  m 

Dec.    15 

900               0 

0               75  ±          +75 

1910 

Jan.       (i 

1110      Slitrht    -r         1.5 

0               00              +00 

12 

992                                1  .  1 

2                                                                     0.20 

April     4 

1440              +                1.9 

Trace           55              +55           152!           0.30 

Successfully 

•online,!     of  9!  Il>.    hoy. 

April  25 

1200           ++              1.3 

0                  0 

May   25 

1050             +               2.0 

0               50              +50 

June   22 

1530              0 

0               50              +50 

1917 

Jan.     12 

900              + 

SI.   + 

Mar.  2s 

7MI           ++              1.4 

0                20  ±         2O  ± 

30 

0 

0 

It  will  be  seen  from  this  chart  that  su^ar  was  constantly  present 
in  the  urine  from  May,  1! )()'.>,  until  -January  '2'.\,  101  1,  when  a  pro- 
longed, energetic  attempt  was  made  to  remove  it.  However, 
it  quickly  returned;  it  again  disappeared,  although  with  the 
presence  of  considerable  acidosis,  on  December  ;">,  1(.)14,  this  time 
with  the  help  of  fasting  treatment.  Thereafter  it  remained  absent, 
and  the,  patient  acquired  a  tolerance  for  15  grams  of  carbohydrate 


PREGXAXCY  AXD  DIABETES 


457 


and  lived  strictly  within  this  limit,  even  though  considerable  acidosis 
existed. 

The  patient  became  pregnant,  the  last  catamenia  being  August 
4,  1915,  and  it  was  observed  that  the  tolerance  for  carbohydrate 
gradually  increased.  From  the  chart  it  will  be  seen  that  it  finally 
rose  to  at  least  GO  to  75  grams.  During  the  pregnancy  the  diet 
was  halved  on  one  day  each  week.  Confinement  took  place  unevent- 
fully on  April  30,  1910,  and  the  patient  was  delivered  of  a  9^-pound 
boy.  May,  1917,  finds  both  mother  and  child  doing  well.  The  blood 
sugar  on  January  13,  191(>,  was  0.2  per  cent.,  and  on  January  27, 
1910,  0.19  per  cent.,  when  the  blood-pressure  was  122  systolic  and 
7<s  diastolic. 

TABLE  198. — CASE  Xo.  1070.     PREGXAXCY.     EXTREME  ACIDOSIS.     CESAREAN 
SECTIOX.     LOCAL  AXESTHESIA. 


Urine. 

Diet  in  grams. 

5 

O 

Date. 

° 

& 

3    K 

g 

5« 

It: 

"  ti 

o 

Diacetie 

2- 

c  — 

c 

.0 

£      O 

o^ 

«  t 

—    • 

_5 

acid. 

£        tS 

"    C 
tT    ±1 

•c  '-• 

'Z 

_J    '     ^ 

5  § 

"5  t 

O  & 

\  z 

> 

£       y.    £• 

o 

- 

z     y   ^ 

E 

< 

1916 

June  22    3100 

+  + 

13.3    1.9 

93 

101 

24 

0      500    121     (I 

23    2500 

+  -j- 

05       S9 

22 

444    122     0 

21 

20 

24    2900 

-f 

41   1    89 

22 

0      444 

.      0 

21 

25    1500         SI. 

..      1.0 

12       05 

17       .  .       328    124     0 

20    2000  i       SI. 

.  .      1.7 

4 

50 

10         0      240 

0 

29 

27    2000  !       SI. 

0       30 

5         0      140    125     0 

31 

2S    1SOO 

0 

0 

10 

5         0 

GO    120     0 

0.13     28 

July    14    2300 

0 

0 

04 

70 

105 

1481    122     0      .  . 

0.13 

Aug.  31  ,     .  . 

0 

0 

.      :    0     I 

Delive 

ry  by   Ces:area|nsec' 

:ion  —  lo 

cal  anes 

the  si!a. 

Sept,    1      700 

0 

0         0 

22       30 

382 

.     ;    0 

1 

2      900 

+ 

.  .        0       51 

19       2s 

532 

.        0        .  . 

.  .       28 

3      800 

+  -f- 

.  .    1     0 

47 

34       37 

057 

.      0      .  . 

29 

4      000 

+ 

0       47 

34       37 

057 

.      0 

32 

5 

800 

0 

.  .        0       70 

44  i    50 

960 

.      0 

33 

25 

2570 

0 

0         Mi 

s2     180 

2280    1 

J9     0 

1917 

Feb.   2S      800 

_l  1  I 

22 

0 

Mar.     1  ,    700 

+  +  +  + 

.  .    i   12         0 

0         0  ,        0 

.      0      .  . 

0.33 

29 

2    1000 

+ 

0  ;      0 

0^0^        0 

.      0 

3  i  1900 

0 

0 

0 

000 

.     o 

19    1400 

0 

..        ..         1 

18 

52     101    1189 

.      0      .  . 

0.24 

In  Table  198  is  shown  the  course  of  Case  Xo.  1070  who  in  the 
sixth  month  of  pregnancy  entered  the  New  iMigland  Deaconess 
Hospital.  She  had  severe  acidosis,  for  the  COo  tension  in  the  alve- 
olar air  was  20  mm.  Ilg  and  the  CO2  in  the  blood  21  in  terms  of 
mm.  tension  Hg.  Under  the  care  of  my  assistant,  Dr.  Ilornor,  she 


4f)X  TREATMENT 

became  acid-  and  sugar-free,  went  home  and  returned  at  the  begin- 
ning of  labor.  A  Cesarean  section  was  successfully  performed  by  J. 
('.  Ilubbard  under  local  anesthesia.  The  mother  and  child  remain 
in  good  condition  at  this  writing,  May,  1917,  but  the  tolerance  of  the 
mother  for  carbohydrate  has  decreased  to  a  few  grains  just  as  it  has 
to  a  lesser  degree  in  Case  No.  430. 

O.     DIABETES  IN  CHILDREN. 

It  is  unfair  to  base  a  prognosis  upon  the  course  of  diabetes  in  a 
child  by  the  unfavorable  records  of  the  past.  There  are  but  few 
cures  of  diabetes,  but  the  few  which  are  on  record  have  most  often 
occurred  in  children,  and  there  is  always  the  possibility  that  this  is 
the  exceptional  case  which  may  recover.  While  the  parents  are 
told  the  usual  outcome  of  such  cases,  they  should  be  given  hope 
until  the  outcome  of  the  disease  in  a  given  child  is  plainly  evident. 

Whereas  formerly  the  prognosis  for  children  under  ten  years  of 
age  was  measured  in  months,  today  it  is  rare  for  a  child  to  live  less 
than  one  year.  Among  my  cases  there  have  been  .">!•  who  developed 
the  disease  within  the  first  decade,  and  of  these  3<S  have  died.  In 
order  to  show  the  result  which  change  of  treatment  has  wrought, 
I  have  divided  these  cases  chronologically  into  two  groups,  those 
seen  prior  to  December  1,  1914,  and  those  treated  from  that  date 
to  the  present  writing,  and  in  order  not  to  confuse  the  picture  by  the 
7  cases  who  have  lived  over  five  years,  I  have  placed  these  cases  in 
one  section  of  the  table  and  the  remaining  52  cases  in  another. 

TAHLE  199. — DIAHETKS  ix  THK  FIHST  DECAUE  OF  LIFE. 


Period.  5  Dead.  T,   .;,,',„  Dead 


Alive 
Doc.  1,   Kill1,. 


Years.         I**'         Years.         Total         V(,a,.^ 


.  S 


Total  dead,  .'is;  average  duration,   1.1  years. 
Total  living,  L'l  ;  average  duration.  L'.li  years. 


Table  199  shows  that  the  duration  of  life  of  all  the  fatal  cases  has 
been  one  and  four-tenth  years,  and  that  the  duration  of  life  of  all 


DIABETES  IN  CHILDREN  459 

the  living  cases  has  already  reached  two  and  six-tenth  years.  This 
does  not  include  Case  Xo.  887,  p.  359,  who  lived  twenty-nine  years. 
This  latter  figure  is  somewhat  misleading  because  of  the  number  of 
living  cases  whose  duration  has  been  over  five  years.  To  me  the 
value  of  this  table  lies  in  the  15  living  cases  seen  since  December  1, 
1914.  Their  average  duration  has  already  exceeded  by  nearly  50 
per  cent,  the  average  duration  of  30  fatal  cases  seen  prior  to  that 
time.  Since  December  1,  1914,  there  have  been  0  deaths  in  the 
24  children  seen;  2  of  these  occurred  in  children  with  a  duration 
of  the  disease  of  less  than  one  year,  and  4  died  between  the  first  and 
second  years.  Of  the  18  cases  seen  during  this  period  who  are  still 
alive,  4  have  already  lived  more  than  two  years.  Contrast  these 
facts  with  the  statement  of  a  well-known  diabetic  author,  published 
in  1915:  "Two  years  from  the  time  of  the  first  symptoms  is  the 
longest  time  that  has  come  to  my  observation." 

Children  make  exceptionally  good  patients.  This  is  probably 
due  to  an  early  discovery  of  the  disease  and  to  vigorous  treatment. 
Almost  invariably  children  become  sugar-free  for  a  shorter  or  longer 
period.  The  diet  is  borne  unusually  well,  and,  as  a  rule,  without 
complaint.  In  favorable  cases  growth  takes  place  quite  as  in  healthy 
children,  and  it  is  this  growth  which  often  deceives  the  physician 
and  relatives  into  believing  that  the  disease  has  disappeared,  and 
has  led  to  relaxation  in  treatment.  In  other  cases  growth  is  retarded. 
In  such  instances  it  is  encouraging  to  remember  that  Osborne  and 
Mendel1  state,  as  a  result  of  their  experiments  upon  animals,  that 
"  after  periods  of  suppression  of  growth,  even  without  loss  of  body 
weight,  growth  may  proceed  at  an  exaggerated  rate  for  a  considerable 
period.  This  is  regarded  as  something  apart  from  the  rapid  gains 
of  weight  in  the  repair  or  recuperation  of  tissue  actually  lost. 
Despite  failure  to  grow  for  some  time  the  average  normal  size 
may  thus  be  regained  before  the  usual  period  of  growth  is  ended." 

The  methods  of  treatment  of  children  with  diabetes  are  precisely 
those  of  adults.  Rigid  dieting  offers  more  comfort  to  the  child  than 
to  allow  freedom  in  eating,  and  furthermore,  I  am  convinced  that 
rigid  dieting  is  more  effective  in  prolonging  life  than  neglect  to 
follow  dietetic  rules.  Case  Xo.  813,  a  little  boy,  remained  sugar- 
free  for  a  considerable  length  of  time  after  returning  home  from  the 
hospital.  He  was  then  given  cherries  to  eat,  which  was  not  in 
accordance  with  his  diet.  From  that  time  on  it  was  difficult  to 
maintain  adherence  to  rules. 

Parents  occasionally  renounce  regulation  treatment  and  adopt 
quack  methods.  In  not  a  single  instance  has  the  child  done  as  well 
as  before  the  change  was  made  and  my  statistics  pay  the  penalty. 

1  Osborne  and  Mendel:  Am.  Jour.  Physiol.,  191G,  xl,  p.  16. 


4(>0 


TREATMENT 


The  diet  of  children  with  diabetes  from  the  age  of  two  upward 
requires  surprisingly  few  modifications  of  that  of  an  adult.  Fasting 
is  borne  perfectly  well  for  a  few  days,  and  with  comparatively 
little  complaint.  Even  the  complication  of  a  slight  temperature 
and  a  croupy  cough  (not  diphtheria)  does  not  interfere  with  the 
fasting  treatment.  Such  symptoms  were  present  during  the  first 
few  days  of  hospital  treatment  of  Case  No.  9oX,  whose  dietetic  and 
urinary  charts  arc  recorded  on  page  4S5.  Following  the  period  of 
fasting  the  addition  of  50  grams  of  5  per  cent,  vegetables  with 
broths  goes  a  long  way  toward  relieving  hunger,  and  subsequent 
weekly  strict  diet,  days  cause  no  trouble  if  broths  and  300  grams  of 
5  per  cent,  vegetables  can  be  allowed.  Especial  pains  should  be 
taken  in  the  preparation  of  the  vegetables,  for  children  eat  fast 
and  occasionally  diarrhea  results.  Strange  to  say,  more  frequently 
the  complaint  is  of  constipation.  Children's  specialists,  accustomed 
to  dealing  with  children  of  delicate  digestions,  sometimes  err  in 
making  the  diet  too  simple.  In  my  experience  with  diabetic  children 
two  or  three  years  of  age  and  over,  they  easily  bear  the  diet  of 
adults  if  reasonable  care  is  taken. 

The  quantity  of  protein  required  by  the  child  is  proportionately 
more  than  that  of  an  adult.  So  far  as  I  can  learn  from  the  published 
data,  .')  grams  of  protein  per  kilogram  body  weight  is  the  amount 
which  the  normal  child  of  about  four  years  requires.  As  age 
advances  this  gradually  decreases  to  1  gram  or  1.5  grams  for  the 
adult.  The  following  table  shows  the  nitrogenous  urinary  excretion 
of  four  healthy  children  selected  for  their  health  and  size  from 
among  the  playmates  of  some  of  my  diabetic  children. 


TAHLE    200. — THE   XITKOCJEN  AND  SALT  IN  THE  TUIXES  OF  FOUR  HEALTHY 

CHILDREN. 


Nf.        Weight.  VJ.     Sp.gr.     NaCl, 


1910 

Oct.  IN    19  ;  <".  I'.        '  2  yrs.  10  inns.  '  Us.}      :5I5  11,. 

19  20 

20  21 


11         :54  11>.  M  oz. 


20   21     A.  ('.          4  vrs.  2  inns 


1016 


21  2.">    I).  J.,  Jr.  »  yrs.  0  mos.       10^     -11  11>.  l.'i  <>z.      s70       KIM 

son      101:5 


DIABETES  IN  CHILDREN  461 

I  am  quite  open-minded  upon  the  question  of  the  proper  quantity 
of  protein  for  the  child,  but  at  present  I  try  to  give  3  grams  per 
kilogram  body  weight.  Possibly  one  should  give  much  less.  The 
quantity  of  protein  in  broth  must  be  considered  in  planning  the 
diet  of  children.  One  specimen  of  broth  showed  36  grams  to  the 
liter. 

The  quantity  of  carbohydrate  is  determined  by  the  same  methods 
as  in  adults.  Tolerance  tests  are  demoralizing,  because  the  child 
cannot  reason  out  why  so  much  food  of  the  character  he  enjoys 
should  be  good  for  him  one  day  and  not  the  next.  It  is  better 
policy  to  keep  the  carbohydrate  low  rather  than  near  the  toleration 
limit.  The  Eskimo  children  have  little  carbohydrate  and  thrive, 
and  so  ought  diabetic  children  with  practice.  New  tests  in  treatment 
should  be  worked  out  upon  adults;  a  colt  needs  a  steady  rein.  In 
giving  carbohydrate  to  a  child,  do  not  forget  that  the  addition  of  5 
grams  carbohydrate  to  the  diet  of  a  child  weighing  15  kilograms  is 
proportionately  equal  to  the  addition  of  20  grams  to  that  of 
an  adult. 

Fat  has  been  the  stumbling-stone  in  the  pathway  of  the  treatment 
of  diabetic  children  in  the  past.  Children  require  many  calories 
and  seldom  can  get  along  on  less  than  50  per  kilogram  body  weight, 
but  they  are  very  susceptible  to  the  development  of  acidosis  and 
when  the  acid  danger  lurks,  beware!  The  addition  of  an  egg  con- 
taining only  6  grams  of  fat  brought  out  a  marked  acidosis  in  Case 
No.  938  (see  p.  485)  on  October  28.  A  few  days  later,  when  the 
child  had  become  accustomed  to  fat,  32  grams  were  taken  with 
impunity.  No  longer  is  it  true  that  all  of  my  diabetic  children 
have  died  of  acidosis,  for  one  succumbed  to  inanition;  but  with  37 
out  of  38  deaths  due  to  one  cause  there  is  no  question  as  to  what 
the  enemy  is.  And  as  acidosis  is  due  to  fat  not  being  oxidized,  we 
must  strive  in  every  way  to  favor  its  oxidation  by  increasing  the 
tolerance  for  carbohydrate. 

The  restricted  diet  of  children  may  possibly  conceal  dangers  due 
to  the  absence  of  salts  of  one  kind  or  another.  To  avoid  such  a 
contingency,  raw  vegetables  are  prescribed  freely  and  I  always  like 
to  give  a  little  cream  for  the  sake  of  the  calcium. 

Even  if  che  tolerance  is  above  50  grams,  I  believe  it  wiser  to 
keep  the  diet  at  or  below  that  figure.  The  prognosis  in  children  is 
so  grave  that  no  chances  should  be  taken.  Furthermore,  it  is  a 
great  disappointment  to  all  to  cut  down  the  allowance  of  carbohy- 
drate, and  therefore  one  should  try  to  avoid  it.  It  is  better  not  to 
give  children  saccharin.  Strict  dieting  must  be  carried  out  for 
such  a  long  period  that  it  is  kinder  to  the  child  and  easier  for 
him  to  give  up  the  taste  of  sweets.  For  this  reason,  various  diabetic 
breads  are  not  to  be  encouraged.  Meat,  eggs,  vegetables,  butter, 


402 


TREATMENT 


cream,  nuts,  cheese,  and  possibly  fruits  of  the  5  and  10  per  cent, 
groups  should  form  the  permanent  diet.  Temporarily,  I  often 
employ  sugar-free  milk,  but  eventually,  as  tolerance  grows,  sub- 
stitute cream  for  it. 

Exercise  has  also  been  beneficial  even  when  it  has  been  violent. 
Case  No.  7S5,  who  took  no  exercise  and  made  no  exertion,  improved 
very  slowly  as  compared  with  Cases  Nos.  92")  and  !)2)>,  who  played 
tennis  and  walked  miles.  All  the  children  appear  to  do  better  when 
taking  exercise.  I  shall  take  pains  in  the  future  to  provide  massage 
for  those  confined  to  bed.  \Ye  must  never  forget  that  one-half  the 
glycogen  in  the  body  is  stored  in  the  muscles,  and  that  undoubtedly 
fully  as  much  of  the  carbohydrate  ingested  is  there  burned. 

In  addition  to  the  following  illustrative  cases,  other  cases  in 
children  are  described  on  pages  4S4  and  485. 

TABLE  201.— CHART  OF  A  CHILD,  CASE  No.  1209,  AGED  8  YRS.,  6  Mos.,  SHOW- 
IXC;   H()\V    HE   CoNQUEKKD    IllS   TENDENCY   TO    EAT  CANDY. 


Diet  in  grains 


Urine. 

Svifjar. 

Date, 

« 

'Z 

1917. 

£ 

a 

M 

''     PCI 
£      ct. 

To- 
tal 

"3 

rt 

K111S. 

.Ian.  1 

Spec. 

0      '.).<) 

1-  2 

300 

0      4  .  ( 

12 

•2-  3 

.')()() 

.       0   I 

3 

3-  4 

(500 

Tr.    0.1 

1 

4      .') 

1000 

0      31 

31' 

5-   (i 

325 

o     o.: 

1 

(i-  7 

500 

0  :  o 

0 

7-  X 

550 

0      (t.l 

11 

X-  9 

300 

(I         0 

0 

9-10 

150 

0        0 

0 

10-11 

775 

0      1.7 

13' 

11-12 

<;oo 

0        (1 

0 

12-  13 

,soo 

0         0 

0 

lii-17 

X(  )(  ) 

0         0 

0 

17-  is 

soo 

0      0. 

(1 

IS-  19 

1  10(1 

0         0 

1) 

22   27- 

1240 

0         1) 

0 

27  -2.S 

1300 

o       o 

1) 

Case  No.  9)>X  illustrates  the  preliminary  treatment  of  a  child 
two  years  old,  and  is  given  in  detail  m  Section  \  1  (see  p.  -IS")). 
Cases  Nos.  (.>2:>  (see  p.  -1X4)  and  (.>2.">  (see  below)  illustrate  fasting 
treatment.  To  the  latter  a  fe\v  grains  of  carbohydrate  were  allowed 
instead  of  complete  fasting,  but  with  the  former  this  was  not  indi- 
cated because  he  became  sugar-free  so  quickly. 

rpon  the  first  three  days  at  the  hospital  the  urine  of  Case  No. 
!)2.")  contained  respectively  o.(>  per  cent.,  ().(>  per  cent  sugar,  and 

1  Ate  candy.  -  Average  for  6  days. 


DIABETES  IN  CHILDREN 


4f>3 


then  became  levorotatory.  On  the  fourth  day  it  was  sugar-free.  The 
diet  for  the  first  day  consisted  of  one  orange  and  50  grams  5  per 
cent,  vegetables;  for  the  second  day  one  orange  and  150  grams  5 
per  cent,  vegetables;  the  third  day  was  fasting  except  for  broth; 
the  fourth  day  to  the  broth  were  added  30  grams  5  per  cent,  vege- 
tables. After  that  the  diet  was  increased  by  approximately  5  grams 
carbohydrate  a  day  up  to  39  grams. 

TABLE  202.— CHART  OF  A  CHILD  AGED  2  Yns.,  6  Mos.     CASE  No.  1199. 


Urine. 

Diet  in  grams. 

Dietary  prescriptions  in  grams. 

Sugar. 

= 

ft 

d 

Date, 

0 

3 





2 

"5 

E 

E 

hi 

5 

C.    • 

1917. 

0 

T3 

2 

6 

o 

3 

0 

Per 

To- 

a 

- 

cc 

z 

[3 

o 

u 

bt 

«3 

E 

o 

tal 

- 

-^  c 

•s. 

^ 

s- 

CH      r* 

0) 

~ 

ct. 

•£ 

^ 

c 

M 

8,3 

— 

J5 

.% 

D3 

w: 

be 

•+» 

c  ^ 

^j 

Q 

•  2* 

_,nis. 

_ 

2 

a 

_?; 

c3 

<o 

03         C 

tn 

J3 

- 

—  ^ 

bj 

c 

^    ^ 

3 

> 

P 

o 

t. 

< 

c- 

S-* 

C        O 

£ 

o 

•^ 

CO 

w 

u 

P3 

Dec. 

4 

Spec. 

0 

6.3 

15 

5 

780 

0 

5  .  3 

41 

8 
13 

Spec. 

0 
0 

2.4 
1.2 

35 
32 

Carbohydr 
En  tra  nee 

ate 
to 

only  j  part 
hospital. 

lye 

lim 

inat 

ed. 

15 

330 

0 

0    1 

16 

510 

Tr. 

0 

0 

15 

11 

0    0 

108 

300 

0   0.5 

30 

0 

0 

0 

0 

17 

480 

Tr. 

0 

0 

25 

28 

3    0 

229 

32 

300115   0.5 

!K) 

00     30 

0 

18 
19 

20 

630 

540 
290 

0 
0 
0 

0 
0 
0 

0 
0 
0 

30 

in 

41 
42 
43 

17 
24 

21 

0 
0 
0 

437 
544 

572 

•• 

si 

300  ,  15 
300  :  30 
300   30 

1.0 
1.0 
1.0 

90 
0 
0 

0   0 
60   0 
60   0 

60 
60 
60 

2 

2 
2 

30 

21 

420 

0        0        0 

53 

45   30   0     662 

300   30 

1.0 

0 

00 

0 

60 

2     60 

30 

22 

480 

000 

60 

47 

40   0 

788 

300  :  30 

1.0 

0 

0 

60 

00 

2    90     60 

0 

Case  Xo.  814  shows  the  course  for  over  two  years. 

TABLE  203. — -CASE  No.  814.     AGE  AT  OXSET,  TWELVE  YEARS. 


Date. 

Volume, 
c.c. 

Diacetic 
acid. 

Ammo- 
nia, 
grams. 

Total 
sugar, 
grams. 

Diet 

in  Grams 

NaliCOs 

Blood 

sugar, 
per  pent. 

Garb. 

Protein.    F; 

lt        grams. 

1915 

Jan.      3 

11,500 

920 

0 

41 

4,000 

6 

.  1,200  + 

+  +  + 

1.8 

12  + 

20 

7 

2,882 

+ 

0 

0 

0 

0          24 

19 

1,530            0 

0 

50 

GO         90            0 

Mar.  m 

0 

0.17 

May  21 

0 

0.15 

Nov.  10 

0 

0.6 

0 

0.13 

IS 

0 

0 

35 

0 

1917 

Jan.     lo 

0 

0 

52 

62         OS            0 

0.18 

Mav  L'G 

__"_ 

0 

0 

03 

Gl         80            0 

Case  Xo.  295  is  reported  in  detail  in  Publication  13(>  of  the  Car- 
negie Institution  of  Washington,  I).  C.,  1910,  page  120;  and  also 

1  Fat -protein  diet. 


4b'4  TREATMENT 

Publication  17(>,  1912,  page  21.  The  case  is  inserted  here  because 
of  the  exceptionally  long  duration,  which  may  \w  explained  by  the 
presence  of  a  diabetic  heredity. 

Case  No.  295;  male;  born  February  2,  lSS(i;  married;  chauf- 
feur; came  under  observation  October  25,  1909;  onset  of  diabetes 
at  the  age  of  fourteen  years  in  1900;  death  in  coma  in  May,  1912. 

Fain ih/  History.— Yather  died  of  diabetes,  complicated  by 
appendicitis,  at  age  of  fifty-one  years,  having  been  ill  with  the 
disease  for  two  or  three  years.  One  brother  died  of  diabetes  at  the 
age  of  eleven  years.  The  mother  has  gall-stones.  Two  brothers 
and  one  sister  well.  The  patient  was  married  September,  1907, 
and  has  one  child  in  fairly  good  health,  five  months  old. 

Paxt  History. — A  frail  boy;  scarlet  fever,  measles,  chicken-pox, 
whooping-cough.  October,  1907,  typhoid  fever. 

I'rctit'iit  Ill/u'M. — The  date  of  onset  is  not  accurately  known, 
but  during  1X99  the  patient  was  thirsty  and  arose  several  times  a 
night  to  void  urine.  In  May,  1902,  sugar  was  found  in  the  urine. 
Dr.  Oscar  ().  Roberts,  who  examined  the  patient  at  that  date,  said 
that  the  indications  were  that  sugar  had  been  present  for  some 
time  previous.  Sugar  was  absent  from  the  urine  for  a  brief  period 
in  1901.  Since  the  onset  of  the  disease  the  patient  has  worked 
steadily,  only  occasionally  losing  some  time,  as  during  an  attack 
of  typhoid  fever,  and  on  account  of  a  furuncle  on  the  heel.  lie 
began  his  occupation  as  chauffeur  in  April,  1909. 

The  greatest  quantity  of  urine  noted  in  twenty-four  hours  was 
12  quarts,  and  upon  October  2o,  1909,  the  quantity  measured 
amounted  to  10  quarts.  The  patient  has  a  mania  for  ice-cream 
sodas.  lp  to  October  1  the  patient  felt,  in  fairly  good  health, 
but  was  then  especially  upset  because  he  could  not  get  the  diet  to 
which  he  had  been  accustomed,  being  forced  to  live,  while  upon  a 
visit,  chiefly  upon  sugar  and  starch.  lie  now  "eats  any  time."  No 
headache.  He  is  recovering  from  a  cough,  but  has  no  sputum. 

Phij^'n-dl  Examination.-  The  greatest  weight,  dressed,  was  (>O.X 
kilograms;  on  October  25,  1909,  it,  was  19.5  kilograms.  Height, 
17C>  cm.  Typical  gaunt,  flushed,  dry  appearance.  Reflexes  normal; 
eyelids  red;  teeth  in  good  condition;  tip  of  tongue  red  and  back  of 
tongue  slightly  dry;  lungs  and  heart  normal;  pulse,  12S,  blood- 
pressure,  100.  "Acetone"  odor  to  breath,  and  whole  room  filled 
with  it- 
An  attack  of  influenza  in  the  spring  of  1910  reduced  the  strength 
of  the  patient  materially,  yet  he  recovered  sufficiently  to  go  into 
the  poultry  business.  He  did  not  limit  his  diet,  and  it  included, 
among  other  articles,  2  quarts  of  milk,  (>  oranges,  and  10  eggs  daily. 
In  I'Ybruary,  1911,  he  returned  to  the  hospital  on  account  of  diar- 
rhea, which  had  existed  for  some  time.  I  uder  hospital  care  the 


DIABETES  IN  CHILDREN 


4G5 


number  of  stools  decreased  from  12  to  5  daily,  and  his  condition 
improved.  During  1911  the  patient's  condition  did  not  change. 
He  agreeably  passed  the  early  winter  in  Florida,  but  in  February, 
1912,  as  the  diarrhea  had  returned,  again  entered  the  hospital  for 
a  few  days.  Except  for  emaciation  and  weakness  and  the  presence 
of  numerous  furuncles,  his  condition  had  changed  but  little.  Death 
took  place  in  coma  several  weeks  after  his  return  home  in  May,  1912. 

Case  No.  304;  female;  age  at  onset  thirteen  years;  came  under 
observation  at  the  age  of  twenty-one  years  on  November  24,  1909, 
and  died  in  coma  on  January  4,  1910,  following  restricted  diet  and 
unusual  exertion. 

Family  History. — Several  of  the  family  died  of  diabetes,  the 
grandmother  at  thirty-five,  the  mother  at  forty-one,  and  a  brother 
at  twenty-five;  another  brother  has  had  the  disease  for  six  years. 
One  brother  well,  one  brother  died  of  pneumonia  at  twenty-eight, 
a  sister  of  diphtheria  at  four. 

Past  History. — The  only  illness  observed  was  measles.  Cata- 
menia  began  at  the  age  of  thirteen  and  continued  until  the  end. 
Symptoms  of  diabetes  also  appeared  when  the  patient  was  thirteen. 
When  first  seen  she  appeared  in  far  better  condition  than  one  would 
expect.  She  was  nervous,  the  eyes  were  prominent  and  her  hair 
had  been  falling  out,  but  the  thyroid  was  normal.  The  pulse  was 
92,  blood-pressure  130;  there  were  scars  of  tubercular  glands  in 
the  neck,  but  the  physical  examination  otherwise  was  negative. 
The  diet  was  restricted,  and  at  first  the  patient  did  well,  but  during 
the  Christmas  vacation  she  grew  very  tired  one  night  at  a  dance, 
returned  to  Boston  for  school  the  next  day,  and  became  exhausted 
with  the  weight  of  a  heavy  bag  which  she  carried  a  long  distance 
and  in  a  few  hours  was  in  coma. 

The  data  regarding  four  children  under  observation  are  recorded 
in  Table  204. 

TABLE  204. — DIETARY  CHARTS  OF  FOUR  CHILDREN-  PRESENT  OR  REPRESENTED 
AT  THE  TUESDAY  MORNING  CLINIC  AT  THE  NEW  ENGLAND 
DEACONESS  HOSPITAL,  FEBRUARY  29,  1916. 


Age. 

Diet. 

,,,    .    i   ,     C.'ilor- 

Duration, 
April  1, 

V\  eifzht,   - 

Case  No. 

At 

onset, 

Feb., 

1010, 

Carbo- 
hydrate, 

Protein, 

Fat, 

Calor-     kllos-       kilo 

1917, 

yrs. 

yrs. 

yrs. 

Kms. 

S94 

1.3 

3.6 

30 

30 

54 

702        10          50 

3.4 

997    . 

7.7 

S.O 

33 

59 

75 

1043        20          52 

15 

995   .      .       . 

0.0 

0.2            44 

45 

84 

1112        19          59 

1.3 

950   .      .       .           2.1          2.7 

24 

41 

70 

944        12          79 

1.8 

The  chart  is  recorded  here  because  by  chance  the  children  or  the 
mothers  of  three  were  present  at  the  clinic  February  29,  1916,  and 
30 


Kit)  TREATMENT 

a  letter  was  received  the  previous  day  from  Case  No.  SOI.     The 
cases  therefore  reveal  actual  conditions. 

Inspection  of  the  chart  shows  that  Case  No.  050  is  receiving  the 
highest  number  of  calories — undoubtedly  too  high,  I  should  say, 
writing  in  the  spring  of  1917.  A  year  ago  she  did  so  well  I  hesitated 
to  make  a  change.  Later  she  showed  sugar,  but  under  observation 
in  the  hospital  became  sugar-free.  In  the  autumn  the  tolerance 
became  almost  nil,  and  I  asked  Dr.  Allen  and  Dr.  Fit/,  at  the 
Rockefeller  Institute,  to  take  her  as  a  patient.  She  improved  at 
the  Hospital  of  the  Rockefeller  Institute  and  was  discharged  with 
a  tolerance  for  7  grams  carbohydrate.  This  case  has  proven  to  be 
the  most  severe  of  the  four  children  and  it  is  noticeable  that  a  year 
ago  the  diet  of  this  child  was  very  much  higher  in  calories  than 
that  of  any  of  the  others  even  when  the  ages  are  taken  into  account. 
Case  Xo.  S04  is  holding  her  weight,  but  should  have  more  calories; 
probably  55  to  00  per  kilo  body  weight  per  twenty-four  hours 
would  be  borne  well.  Xo  change  need  be  made  in  the  calories 
which  Case  Xo.  005  receives,  for  his  case  is  a  recent  one  and  his 
weight  is  practically  constant.  Case  Xo.  007  is  also  a  recent  one 
and  I  am  not  inclined  to  raise  the  calories  at  present. 

P.     DIABETES  IN  OLD  AGE. 

Diabetes  frequently  occurs  in  old  age.  The  onset  in  25,  or  2  per 
cent.,  of  my  cases,  took  place  above  the  age  of  seventy  years. 
It  is  often  claimed  that  such  patients  need  no  treatment,  and  are, 
in  fact,  better  off  without  it.  To  this  statement  I  cannot  agree 
until  figures  supporting  such  a  position  are  furnished.  It  is  true  that 
four  of  the  twenty-five  patients  have  outlived  the  normal  expecta- 
tion of  life  of  individuals  of  the  same  age  at  which  they  developed 
diabetes.  This  point  of  view  of  prognosis  in  diabetes  is  interesting 
and  I  shall  follow  the  lead  farther.  (See  Table  205.) 

The  treatment  of  elderly  patients  must  be  undertaken  with  greal 
caution.  I  hesitate  to  interfere  with  the  daily  habits  of  any  indi- 
vidual who  has  succeeded  in  living  over  three  score  years  and  ten. 
Hut  if  upon  thorough  study  of  the  case  it  appears  that  the  patient 
is  losing  ground  or  is  hampered  by  diabetic  symptoms  or  com- 
plications, there  should  be  no  hesitation  in  active  treatment. 

Treatment  of  elderly  patients  should  be  begun  most  gradually, 
there  must  be  no  haste;  supervision  should  be  close  and  all  sur- 
roundings made  favorable.  Hearing  in  mind  the  vulnerable  kidneys 
of  elderly  patients,  acidosis  should  be  avoided  under  all  circum- 
stances. Sodium  bicarbonate  should  not  be  employed,  because 
ol  the  marked  variation  in  the  water  content  of  the  body  which 
follows  its  use.  Dietetic  changes  should  be  so  slowlv  introduced 


DIABETES  IN  OLD  AGE  407 

as  to  disturb  the  equilibrium  as  little  as  possible.  Do  not  con- 
fine the  patient  to  the  bed.  All  of  these  regulations  are  met  by  a 
preliminary  withdrawal  of  fat  from  the  diet.  If  the  urine  does  not 
become  sugar-free  in  consequence,  so  soon  as  the  total  quantity 
of  sugar  in  the  urine  does  not  continue  to  show  a  steady  daily  dimin- 
ution, the  protein  and  carbohydrate  should  be  halved.  Should 
this  procedure  fail,  the  protein  is  omitted  and  the  carbohydrate 
reduced  to  40  grams  and  halved  the  next  day,  and  on  the  following 
day  entirely  omitted.  Having  determined  the  carbohydrate  toler- 
ance, protein  may  be  quickly  added  up  to  a  gram  per  kilo  body 
weight,  and  fat  gradually  given  until  the  weight  ceases  to  fall. 

TABLE  205. — THE  COURSE  OF  DIABKTES  WITH  ONSET  ABOVE  THE  AGE 
OF  SEVENTY  YEARS. 


Case 

Xo. 


LIVING    CASES. 


A  20  ;it 
onset. 


629  

71 

687  

75 

817  

72 

826  

73 

N97  

79 

899 

83 

1057  

71 

1063  

71 

1093  

77 

Normal 
expectation 
of  life. 

Duration  to 
Dec.  1,  1916, 
years. 

5.5 

6 

8 

.0 

6 

5 

.1 

,3 

5 

5 

.0 

8 

1 

( 

.3 

3 

5 

.6 

3 

4 

.1 

4 

6 

4.7 

2 

2 

4.0 

1 

S 

6.7 
2.5 
0.5 


FATAL   CASES. 


Case 
No. 

90  . 

118  . 

227  . 

234  . 

252  . 

267  . 
2ss 

393  . 

410  . 

4ls  . 

495  . 

597  . 

628  . 


A«P  at 
onset. 


4.7 

5 . 9 
7.1 


7.1 
7.6 
8.0 
7.6 
5.1 
7.6 
<VO 
S .  0 


Duration, 
yrs. 

9.S 
8.0 
2.3 
2.0 
1.0 
5.8 

Uncertain 
1.7 
6.9 
0.9 
4.2 
2.8 
6.3 


Cause  of  death. 

Old  afro. 

Old  atre. 

Arteriosclerosis. 

Cardiac. 

Gangrene. 

Coma. 

Gangrene. 

Cancer. 

Pneumonia. 

Old  atrc. 

Cancer. 

Cardiac. 

Cardiac. 


Elderly  patients  are  often  easily  depressed,  easily  lose  their 
appetite,  easily  acquire  indigestion,  and  the  danger  of  acidosis  is 
by  no  means  slight.  The  patient  should  be  considered  from  a  broad 
stand-point,  and  the  diabetes  viewed  with  a  proper  perspective. 

Illustrative  cases  of  the  success  of  treatment  of  diabetic  patients 


408  TREATMENT 

of  advanced  years  are  numerous.  Case  Xo.  029,  cited  in  detail 
under  Tuberculosis,  page  407,  still  leads  an  active  life  at  the  age  of 
seventy-eight  years,  and  has  lately  taken  up  politics.  Case  Xo. 
f)~)9,  now  aged  seventy-seven  years,  is  in  good  health  following  the 
removal  of  the  prostate  gland  four  years  ago.  Case  Xo.  0X7, 
from  being  a  semi-invalid,  now  enjoys  life.  Case  X"o.  00,  who  devel- 
oped diabetes  at  the  age  of  seventy-nine,  lived  ten  years,  during 
which  time  she  made  frequent  trips  to  the  tropics,  and  finally  died 
in  England.  Case  X'o.  X'M),  in  whom  diabetes  was  known  not  to 
have  been  present  at  the  age  of  eighty-two,  but  in  whose  case  sugar 
was  found  at  the  age  of  eighty-three,  has  been,  according  to  a  letter 
from  her  daughter  recently  received,  "wonderfully  improved  by 
treatment  and  remains  sugar-free."  Old  age  is  no  excuse  for  neglect 
of  diabetic  treatment. 

The  considerable  duration  of  life  after  the  disease  was  discovered 
was  by  no  means  accidental  in  these  cases.  The  patients  were  more 
intelligent  than  a  similar  group  of  diabetic  patients  taken  at  random. 
There  is  not  the  slightest  doubt  in  my  mind  as  to  the  efficacy 
of  treatment.  X'o  more  entertaining  patients  come  under  a  physi- 
cian's care  than  these  alert  old  diabetics. 

Q.     CASES  OF  DIABETES  OF  FIFTEEN  OR  MORE 
YEARS'  DURATION. 

The  duration  of  the  diabetes  in  (12  of  11X7  of  my  cases  has  been 
fifteen  or  more  years.  Of  these  patients,  154  were  males  and  2X 
females,  essentially  the  same  proportion  as  holds  for  all  in  my 
series.  In  5  of  these  cases  the  diabetes  was  discovered  through  a 
routine  examination  of  the  urine,  and  in  12  others  at  a  life-insurance 
examination.  The  striking  etiological  factor  among  these  cases  was 
obesity,  for  this  was  present  in  (10  of  the  02  patients.  The  second 
etiological  factor  of  importance  was  heredity,  which  was  present 
in  21  cases,  or  34  per  cent.,  in  contrast  to  21  per  cent,  for  all  in  my 
scries.  A  history  of  syphilis  was  obtained  in  •'!,  and  in  this  connection 
it  is  interesting  to  note  that  the  patella  reflexes  were  obtained  in  all, 
and  in  only  one  instance  were  they  even  noted  as  being  diminished. 
The  pupils  reacted  in  all  but  one  of  the  cases.  It  is  true  that  all 
of  the  cases  have  not  been  seen  since  they  have  reached  a  duration 
of  fifteen  years,  but  a  large  proportion  have,  and  this,  taken  in 
conjunction  with  the  fact  that  none  of  them  showed  absent  knee- 
jerks,  lends  very  little  support  to  the  idea  that  long-lasting  diabetes 
leads  to  the  so-called  diabetic  tabes. 

Of  the  02  cases,  10  were  severe,  27  moderately  severe,  24  mild, 
and  1  case  appeared  moderately  severe  at  first,  but  later  became 
mild.  Of  the  37  living  cases,  13  very  easily  became  sugar-free  and 


DIABETES  OF  FIFTEEN  OR  MORE  YEARS'   DURATION      409 

have  remained  so  with  a  slight  restriction  of  diet.  Nine  of  the  25 
fatal  eases  were  known  to  have  never  been  sugar-free  from  the  time 
of  the  first  visit  until  death.  The  sugar  disappeared  from  the  urine 
of  1  case  after  a  duration  of  five  years  upon  a  moderate  diet.  It  is 
worthy  of  note  that  in  only  one  instance  among  the  62  was  dietetic 
treatment  completely  neglected. 

The  blood  sugar  was  determined  in  10  of  these  02  cases,  and  the 
results  obtained  are  shown  in  Table  200.  The  high  values  recorded 
in  Case  No.  887,  p.  359,  and  Case  No.  904,  p.  350,  were  found  shortly 
before  their  deaths,  which  today  might  have  been  avoided. 

Of  the  25  fatal  cases,  there  were  7  in  whom  the  diabetes  was  a 
minor  issue  at  the  time  of  death,  and  among  the  37  living  cases,  in 
18  the  diabetes  is  of  apparently  little  consequence.  Should  one 
examine  these  individuals  as  to  the  effect  of  the  diabetes  upon  the 
expectation  of  life,  it  could  be  said  that  5,  or  20  per  cent.,  of  the  fatal 
cases  outlived  their  natural  expectation  of  life,  and  that  the  same 
already  holds  true  for  4  of  the  living  cases. 

TABLE  200. — BLOOD  SUGAR  ix  CASES  OF  DIABETES  OF  FIFTEEN  OH  MORE 
YEARS'  DURATION. 

Case  Blood  sugar,  Case  Blood  sugar, 

No.  per  cent.  Xo.  per  cent. 

IS  ....               ...  919  ....  0.22  to  0.27 

29  ....             0.10  979  .      .       .      .  0.17  to  0.24 

15.5  ....             0.29  1007  ....  0.09  to  0.23 

177  ....             0.25  1022  ....  0.15  to  0.20 

352  .       .      .      .  0.14  to  0.27  1043  ....             0.19 

435  ....             0.13  HOG  ....             0.13 

887  ....  0.15  to  0.43  1111  ....             O.LS 

904  ....  0.21  toO. 30  11G7                                      0.23 


SKCTIOX  VI. 

AIDS  IN  THE  PRACTICAL  MANAGEMENT  OF 
DIABETIC  CASES. 


A.     WHAT  EVERY  DIABETIC  PATIENT  SHOULD  KNOW. 

1.  The  Nature  of  Diabetes. ---Diabetes  is  a  disease  in  which  the 
patient  fails  to  get,  the  full   benefit  of  the  carbohydrate   (starch 
and  sugar)  eaten.     In  some  cases  there  is  difficulty  in  the  assimi- 
lation  of  protein  and  fat.     Diabetes  is  usually  considered  to  be 
due  either  to  disease  of  the  pancreas  itself,  or  of  that  function  of 
this  gland  which  makes  sugar  and  starch  available  for  the  needs 
of  the  body.     The  pancreatic  gland,  often  called  the  sweetbread, 
is  situated  near  the  stomach  and  furnishes  the  most  important 
digestive   juices   of   the   body.     There   is   no   universal    cause   for 
diabetes  known,  but  very  frequently  it  is  observed  in  individuals 
who  are  overweight  or  who  have  gained  weight  rapidly.     One  likes 
to  think  that  the  disease  is  due  to  the  pancreas  being  overworked 
and  tired  out,  but  occasionally  it  must  be  acknowledged  that  some 
of  the  cells  of  the  gland  are  diseased.     Sometimes  it  seems  as  if 
nervous  excitement  interfered  with  its  proper  action. 

The  pancreas  is  also  concerned  in  the  digestion  of  fat  and  pro- 
tein, but  there  is  comparatively  little  derangement  of  these  activi- 
ties of  the  gland  in  diabetes,  the  disturbance'  being  chiefly  con- 
fined to  the  assimilation  of  carbohydrate.  Xo  medicines  are  known 
which  will  replace  the  loss  of  this  power  of  making  carbohydrate 
available  for  the  needs  of  the  body,  but  it  has  been  proved  that 
dietetic  treatment  will  enable  one  to  live  without  it,  and  that  by 
so  doing  the  lost  power  may  he  somewhat  regained. 

2.  Faithful  Treatment  Accomplishes  Much.     Faithful  treatment 
accomplishes  wonderful  results,  but  half-hearted  treatment  avails 
little.     At  present  it  must  be  said  that  treatment  usually  lasts  for 
life.      Professor   Xaunyn,    who   for  a   generation   was  perhaps  the 
leading   socialist   on   diabetes,    wrote:      "  From    my   experience    I 
consider  it.  highly  probable  that   among  the  early  strictly  treated 
cases,    which    originally    were   considered   severe,    but   later   ran   a, 
favorable  course,  there  is  many  a  one  for  which  one  must  thank 

(470) 


WHAT  EVERY   DIABETIC   PATIEXT  HUOrU)   KXOW     471 

this  early  strict  treatment,  while,  on  the  other  hand,  there  can 
he  no  doubt  that  the  cases  which  run  ultimately  a  severe  course 
underwent  little  or  no  care."  Not  infrequently  those  who  have 
diabetes  outlive  their  normal  expectation  of  life. 

3.  Success  Depends   upon  the  Patient. — Diabetes  is  a  disease 
which  depends  upon  the  honesty  and  intelligence  of  the  patient 
for  successful  treatment.     It  develops  character,  for  to  follow  the 
rules  of  diet  involves  constant  self-control.      It  is  painful  to  see 
how    frequently   disobedience   and   ignorance   are    followed    by   a 
downward  course. 

4.  Diabetes:     The  Best  of  the  Chronic  Diseases. — Diabetes  is 
a   clean   disease,   almost   invariably   painless   if  the   patient   lives 
according  to  the  standard  rules  of  treatment,  and  it  is  not  con- 
tagious.    For  all  these  things  patients  should  be  deeply  thankful. 
Those  who  have  it  do  not  usually  look  or  feel  ill.     In  a  way  this  is  a 
misfortune,  for  it  leads  to  neglect  of  treatment. 

5.  A  Sugar-free  Urine  Spells  Improvement. — If  sugar  is  entirely 
removed  from  the  urine,  the  power  of  the  pancreas  to  assimilate 
carbohydrate  improves.     If  the  urine  is  not  free  from  sugar  the 
patient  is  only  holding  his  own,   or  more  likely  growing  worse. 
The  urine  will  become  sugar-free,  by  giving  this  function  of  the 
pancreas  less  work — that  is,  giving  the  patient  less  carbohydrate 
to  eat.     It.  is  often  easier  to  start  improvement  quickly  by  abso- 
lutely fasting  the  patient  for  a  few  meals  or  days. 

0.  Treatment  Depends  upon  Diet  and  Not  Drugs. — The  treat- 
ment of  diabetes  therefore  depends  on  fasting  and  the  rearrange- 
ment of  the  diet  rather  than  upon  drugs.  The  patient  should 
eat  to  live,  not  live  to  eat.  The  quantity  of  food  which  he  can 
safely  eat  depends  not  upon  his  wishes  but  upon  what  he  can 
assimilate.  Xo  food  is  allowable  in  excess  and  the  total  quantity 
of  food  should  be  such  as  to  keep  him  under  weight. 

(a)  Carbohydrate. — The  available  carbohydrates  of  the  diet  consist 
of  starch  and  sugar.  \']xm  the  diet  chart  (pages  4S2  and  4X3)  is  to 
be  found  the  percentage  of  carbohydrate  in  the  common  foods 
and  the  actual  amount  of  carbohydrate  in  oO  grams  (1  ounce) 
of  food.  But  not  all  vegetables  under  the  5  per  cent,  group  con- 
tain 5  per  cent,  of  carbohydrate.  At  one  end  of  the  list  is  lettuce, 
which  contains  not  far  from  2  per  cent.,  and  string  beans  are 
near  the  other  end  and  contain  o  per  cent.  As  there  is  much 
unassimilable  carbohydrate  (cellulose)  in  vegetables,  the  actual 
percentage  of  available  carbohydrate  is  less  than  .">  per  cent.,  and 
it  is  more  accurate  to  reckon  it  empirically  as  .'>  per  cent.,  or  1 
gram  to  the  ounce.  Thus,  !.">()  grains  (o  ounces)  of  5  per  cent, 
vegetables  contain  about  5  grams  carbohydrate. 

(6)  Protein  and  Fat. — Protein  and  fat.  are  the  other  two  con- 
stituents of  the  diet.  Protein,  examples  of  which  are  white  of 


472  AIDS   IX    MAXAUKMKXT   OF   DIAIiKTIC   CASES 

egg,  Iran  of  meat  or  fish,  au<l  curd  of  milk,  is  indispensable  to 
all  patients.  The  quantity  should  not  he  greater  than  that  taken 
by  the  ordinary  individual.  It  is  fortunate  that  it  occurs  in  so 
many  foods  associated  with  fat  and  without  carbohydrate.  From 
protein  carbohydrate  can  l>e  formed  in  the  body  in  severe  cases. 
Fat  does  not  directly  lead  to  the  formation  of  sugar,  but  if  taken 
in  excess  may  indirectly  cause  sugar  to  appear  in  the  urine.  I'ntil 
very  recently  diabetic  patients  were  given  too  much  fat.  This 
is  explained  by  the  fact,  that  only  within  the  last  few  years  has 
it  been  possible  to  determine  whether  the  fat  taken  by  diabetic 
patients  was  assimilated.  Xew  methods  now  show  that  it. 
promptly  accumulates  in  the  blood,  as  is  shown  by  the  frontispiece, 
which  is  a  picture  of  the  blood  of  Case  No.  7N(i.  The  approximate 
content  of  carbohydrate,  protein  and  fat  in  the  foods  commonly 
eaten  is  given  on  the  diet  card,  as  shown  in  Table  211,]).  4X2. 

(c)  Weights  and  Measures  Employed  in  Computing  the  Diet. — 
The  best  diet  for  a  patient  is  most  readily  determined  by  testing 
the  effects  of  weighed  quantities  of  various  foods.  The  patient 
should  learn  how  to  do  this  for  himself  and  should  find  out  how 
much  carbohydrate,  protein  and  fat  lie  is  taking,  and  whether  he 
can  keep  sugar-free  upon  it.  A\ithin  one  week  from  the  beginning 
of  treatment  he  should  be  able  to  estimate  roughly  how  much  food 
he  is  eating  without  the  frequent  use  of  scales.  J$y  learning  at  once 
to  judge  the  weights  of  food  portions,  much  annoyance  is  obviated 
and  the  patient  ceases  to  be  conspicuous  at  table.  In  weighing 
foods  and  calculating  the  diet  it  is  desirable  to  use  the  metric 
system,  for  in  the  end  it  will  be  found  simpler. 

TAIH.K  207. — WKICHTS  AND  MKASTHKS   KMPLOYF.I)  i\  ( 'OMITTIXC  Tin: 

DlAUKTIC    DlKT. 

=  )}()  grains  (actually  2S.4  grams). 

=  '.]()  cubic  centimeters    (actually   2!U>  cubic 

centimeters i  or  2  tablespoonfuls. 
=  1  pound,  or  4.~>l  grams. 
=  1  quart,  or  9K>  cubic  centimeters. 
=   I  kilogram,  or  2.2  pounds 


In  estimating  carbohydrate,  protein  and  fat  in  the  diet,  or  sugar  in 
the  urine  for  clinical  work,  unless  otherwise  directed  by  the  physician, 
enough  accuracy  is  obtained  by  considering  oO  grams  or  .">()  cubic 
cent  i meters  as  equivalent  to  one  ounce  dry  or  liquid  measure. 

The  quantity  of  protein,  fat,  and  carbohydrate  is  recorded  in 
Table  I'll  for  each  i!l)  grams  (one  ounce)  of  the  articles  of  food 
usually  eaten.  Thus  .'!()  grams  of  oatmeal  (weight  before  it  is 
cooked)  contain  20  grams  carbohydrate,  5  grains  protein  and  2 
grams  fat. 


WHAT  EVERY  DIABETIC  PATIENT  SHOULD  KNOW     473 

(//)  The  Quantity  of  Food  Required. — The  amount  of  food  neces- 
sary for  a  patient  is  determined  by  his  weight.  The  weight  of 
a  diabetie  patient  should  always  be  less  than  his  former  greatest 
weight,  Ixx-ause  thus  he  can  be  assured  that  he  is  not  overeating. 
In  this  resjx'et  it  is  better  to  emulate  the  Indian  than  the  Eskimo. 
The  individual  10  per  cent,  and  even  20  per  cent,  below  weight 
may  not  l>e  a  delight  to  our  eyes,  but  if  over  thirty-five  years  of 
age  and  in  this  condition  he  is  much  more  acceptable  to  the  insur- 
ance company.  It  is  often  desirable  for  a  patient  to  lose  weight, 
but  this  should  bo  undertaken  only  under  the  doctor's  direction. 
Frequently  it  is  only  by  losing  weight  that  a  patient  regains  the 
power  to  tolerate  carbohydrate. 

(<>)  Calories. — The  proper  quantity  of  food  can  also  be  deter- 
mined by  estimating  the  calories  in  the  diet.  A  calorie  represents 
the  heat  which  is  necessary  to  raise  1  kilogram  (2.2  pounds)  of 
water  1°  C.,  or  4  pounds  of  water  1°  F.  For  each  kilogram  body 
weight  per  twenty-four  hours  it  has  been  found  that  an  individual 
requires  at  rest  25  calories,  and  at  light  work  30  calories. 
The  heat  which  is  liberated  in  the  body  from  the  combustion  of 
1  gram  of  protein  or  carbohydrate  produces  4  calories,  and  from  1 
gram  of  fat  9  calories.  From  these  figures  it  is  easy  to  estimate 
approximately  the  calories  in  the  diet,  and  to  compare  them  with 
the  number  of  calories  needed.  It  is  not  possible  to  calculate  the 
calories  in  the  diet  with  exactness  unless  frequent  analyses  are 
made  of  the  food  eaten. 

(/)  The  Normal  and  Diabetic  Diets  Compared. — Four-sevenths  of 
the  calories  of  the  diet  in  health  are  made  up  of  carbohydrate 
and  two-sevenths  of  fat  and  one-seventh  protein,  but  in  diabetes 
the  diet  is  composed  almost  exclusively  of  the  latter  two  foods. 
This  is  not  discouraging,  for  until  recently  the  Eskimo's  diet  con- 
tained only  about  one-seventh  carbohydrate.  It  takes  time  and 
exj>erience  to  learn  to  live  successfully  upon  a  diabetic  diet  and 
it  is  only  with  time  that  the  body  adjusts  itself  to  a  diet  with  so 
marked  a  reduction  of  carbohydrate  and  so  marked  an  increase 
in  fat.  It  is  indeed  wonderful  that  it  is  possible  for  the  body  to 
do  so  at  all. 

((/)  Observe  the  Method  of  Making  the  Urine  Sugar-free. — The 
patient  is  expected  to  become  sugar-free  during  the  early  part 
of  treatment.  He  should  observe  and  record  how  this  is  done, 
so  that  if  sugar  reappears  in  the  urine  he  can  follow  the  same 
method  by  himself  and  again  become  sugar-free.  For  this  reason 
it  is  almost  desirable  for  sugar  to  return  before  a  patient  leaves 
the  hospital.  If  the  return  of  sugar  is  promptly  detected,  fasting 
for  twenty-four  hours  will  almost  invariably  eliminate  it.  The 
diet  may  then  be  resumed,  except  that  the  quantity  of  carbo- 
hydrate should  be  reduced,  and  it  may  be  necessary  to  reduce  the 


474        AID*  J.\  MA.\A(;KMK\T  OF  DIABETIC  CAXKS 

total  quantity  of  all  foods.  Even  if  sugar  does  not  reappear,  on 
one  day  each  week  the  diet  should  he  made  more  strict  than  upon 
the  other  days. 

(/;)  Distribution  and  Exchange  of  Carbohydrates.— The  carbo- 
hydrate, in  the  diet  should  be  divided  between  the  throe  meals. 
Kven  if  the  K)  per  cent.,  1  ">  per  cent.,  and  20  per  cent,  vegetables 
are  allowed,  vegetables  from  the  .">  per  cent,  group  should  be 
taken  as  well.  I  snally  it  is  allowable  to  substitute  for  a  given 
quantity  of  f>  per  cent,  vegetables  one-half  as  much  from  the  10 
per  cent,  group,  one-quarter  as  much  from  the  !.">  per  cent.,  or  one- 
sixth  as  much  from  the  20  per  cent.  Exchange  vegetables  for  fruit 
only  under  advice.  So-called  diabetic  foods  often  contain  consider- 
able quantities  of  carbohydrate,  and  usually  contain  so  much  protein 
and  fat  that,  they  should  not  be  taken  by  the  patient  without  due 
allowance  for  the  same.  They  should  not  be  taken  under  any 
circumstances  unless  their  composition  is  known. 

(/)  Special  Dietetic  Rules  and  Hints. — Eat  too  little  rather  than 
too  much.  With  a  return  to  normal  weight  sugar  may  appear. 

All  food  must  be  eaten  slowly,  and  the  coarser  the  food  the  more 
thoroughly  it  should  be  masticated. 

If  in  doubt  about  a  food,  let  it  alone  until  you  have  found  out 
whether  it  is  allowed.  Do  not  yield  to  the  temptation  of  friends  to 
break  the  diet,  for  if  this  is  done  the  plan  of  treatment  is  upset, 
a  week's  time  may  be  lost  and  several  pounds  of  weight  sacrificed. 

Be  especially  careful  to  note  the  eil'ect  of  any  increase  in  carbo- 
hydrate. The  same  rules  hold  for  protein.  The  quantity  of  fat  is 
generally  regulated  by  the  patient's  weight. 

Remember  it  is  always  possible  to  get  articles  of  food  which  arc 
included  in  a  strict  diabetic  diet  for  a  few  meals,  such  as  eggs, 
meat,  butter,  oil  and  even  5  per  cent,  vegetables,  fresh,  raw  or 
canned. 

Quiet  outdoor  work  agrees  with  diabetic  patients.  One  of  my 
cases  who  has  done1  exceptionally  well  has  a  diabetic  garden  and  thus 
provides  liberally  for  bis  table  both  summer  and  winter. 

In  ease  of  illness  curtail  the  fat  in  the  diet  and  if  acid  poisoning 
is  shown  by  the  ferric  chloride  reaction,  omit  fat  entirely. 

7.  Care  of  Teeth. Clean  the  teeth  after  each  meal  and  have 
them  cleaned  by  a  dentist,  every  one  or  two  months.  The  teeth 
should  always  be  kept  in  good  condition.  If  they  are  to  be 
extracted,  take  gas  and  oxygen,  but  no  ether.  Novocain  injected 
cautiously  acts  admirably. 

S.  Care  of  Skin.  The  skin  must  bo  kept  unusually  clean.  Take 
a  tub  bath  daily,  but  avoid  prolonged  cold  baths.  Short  cold  baths 
are  often  desirable.  Protect  the  skin  from  injuries.  Caution 
chiropodists  and  manicurists  not.  to  draw  a  drop  of  blood.  If 
any  infection  occurs,  see  a  physician  at  once. 


WHAT   KVKRY   DIABETIC   PATIKXT   XIIOt'LI)    KX()\V     475 

9.  Treatment  of  Constipation. — The  bowels  should  move  daily. 
Ise  an  enema  if  necessary.  Never  purge  the  bowels,  but  simple 
laxatives,  such  as  one-fifth  grain  aloin,  fluidextract  cascara  sagrada 
10  to  MO  drops,  or  compound  rhubarb  pills,  are  allowable.  Bran 
muffins  made  with  agar  agar1  (see  page  5M1)  and  coarse  vegetables 
or  fruit  for  breakfast  may  prove  sufficient.  If  diarrhea  occurs  go 
to  bed.  keep  warm,  and  drink  hot  water. 

]().  Exercise. — Exercise  freely  for  short  periods  six  times  a  day. 
It  is  desirable  to  walk  after  meals  and  to  arrange  to  get  exercise 
for  the  upper  part  of  the  body  as  well  as  the  lower.  If  the  accus- 
tomed exercise  is  not  taken,  eat  less. 

1 1 .  Best. — Rest  is  essential.     A  tired  child  is  put  to  bed  and 
wakens  refreshed;  one  of  the  most  noted  surgeons  in  our  country 
is  not  ashamed  to  lie  down  for  fifteen  minutes  after  his  luncheon; 
the  best  treatment  for  a  failing  heart  in  heart  disease  is  to  put  its 
owner  in  bed   for  a  week.     Diabetic  patients  should  rest  often, 
should  never  get  tired  and  should  avoid  athletic  contests.     The 
diet  is  designed  to  give  a  rest  to  the  pancreas. 

Forget  you  have  diabetes  and  do  not  talk  about  it  before  others. 
This  is  one  reason  for  not  using  saccharine  and  the  other  is  to  avoid 
the  perpetuation  of  a  sweet  taste. 

^Year  warm  clothes  instead  of  staying  by  the  radiator  or  in  an 
overheated  room. 

^Mental  diversion  is  desirable,  but  anxiety  is  harmful. 

12.  Sleep. — Sleep  nine  hours  or  more  and  get  another  hour  of  rest 
i>y  day.     Short  periods  of  complete  relaxation  yield  maximal  returns. 

1M.  Examination  of  Urine. — To  collect  the  twenty-four-hour 
quantity  of  urine,  discard  that  voided  at  7.00  A.M.,  and  then  save 
in  a  cool  place  all  urine  passed  thereafter  up  to  and  including 
that  obtained  at  7.00  A.M.  the  next  morning. 

The  urine  should  be  tested  daily  before  breakfast.  Usually  all 
that  voided  the  preceding  twenty-four  hours  should  be  saved  and 
mixed.  If  this  is  impracticable,  save  as  much  as  possible  and  test 
the  mixed  specimen.  Enough  liquids  should  be  drunk  to  keep  the 
total  quantity  of  urine  at  1200  to  1500  c.c.  (10  to  50  ounces  in  the 
twenty-four  hours).  If  the  quantity  of  urine  is  larger  and  sugar  and 
acid  are  absent,  it  may  be  that  too  much  salt  has  been  used. 

14.  Test  for  Sugar. — Benedict's  solution  is  used  for  testing  the 
urine  for  sugar  as  follows:  To  about  5  c.c.  (one  large  teaspoonful) 
of  the  solution  add  S  drops  of  urine;  the  test  may  then  be  continued 
in  either  of  the  two  following  ways: 

(1)  Boil  the  mixture  of  the  solution  and  urine  for  three  minutes 
and  set  aside  to  cool  to  the  temperature  of  the  room;  or 

(2)  Place  the  tube  containing  the  mixture  of  the  solution  and  urine 

1  Sco-wccd  make.-  a  snti.-fnrt<>rv  substitute. 


47(1  AIDS  IX   MANAGEMENT  OF  DIAHETIC  CASES 

in  bubbling,  boiling  water,  where  it  must  remain,  with  the  water 
actually  boiling,  for  five  minutes. 

In  either  ease,  if  the  solution  remains  clear,  the  urine  being  tested 
is  sugar-free;  if  a  heavy  greenish  precipitate  forms  it  usually  means 
that  there  is  a  trace  of  sugar;  the  appearance  of  a  yellow  sediment 
indicates  the  presence  of  a  few  tenths  per  cent,  of  sugar  in  the 
urine,  and  a  red  sediment  more1. 

1.").  Visit  to  the  Doctor.  In  consulting  a  physician  take  a  one- 
half  pint  specimen  from  the  twenty-four-hour  quantity  of  urine 
which  has  been  mixed  and  measured.  Record  the  twenty-four- 
hour  quantity  on  the  bottle  with  your  name. 

Enclose  a  list  of  all  food  eaten  at  the  three  meals  during  the 
preceding  day.  Arrange  this  list  so  that  the  names  of  all  the 
different  foods  eaten  are  in  a  vertical  row  with  the  total  quantities 
of  each  opposite.  (See  Tab'e  20S,  p.  477.)  A  careless  report  of  the 
diet  is  exasperating  to  a  doctor.  Keep  a  note-book  in  which  to 
record  all  questions  which  may  arise.  Allow  space  for  the  answers. 
Gradually  the  note-book  will  become  valuable  for  reference. 

B.     DIRECTIONS  FOR  NURSES  IN  CHARGE   OF  DIABETIC 

PATIENTS. 

Diabetes  offers  a  new  career.  When  trained  in  the  care  of  diabetic 
patients,  nurses  are  often  of  more  value  to  the  patient  than  is 
the  doctor.  By  living  in  the  patient's  home  they  can  better  adapt 
the  diet  to  existing  conditions  and  their  opportunity  for  instruction 
of  the  patient  and  family  is  large.  It  is  often  desirable  to  carry  out 
treatment  from  beginning  to  end  with  the  aid  of  a  nurse  in  the 
patient's  home  instead  of  sending  him  to  the  hospital,  and  it  is 
usually  more  economical  for  the  patient,  provided  the  nurse  is 
thoroughly  trained  in  the  disease. 

The  requirements  of  a  diabetic  nurse  are  many — she  must  be 
honest,  accurate,  intelligent,  a  good  companion,  cheerful  and  keen 
as  to  physical  exercise.  Her  knowledge  of  the  diabetic  diet  should 
be  thorough.  She  should  be  able  to  examine  a  urine  for  specific 
gravity,  reaction,  albumin,  sugar  both  qualitatively  and  quantita- 
tively either  by  the  Benedict  or  fermentation  test,  and  test  for 
diacetic  acid;  understand  ho\v  to  quantitatively  estimate  acidosis 
by  one  method  such  as  estimating  the  ammonia  in  the'  urine,  the 
alveolar  ('()..>  with  the  I'Yidericia  apparatus,  or  the  Marriott  method. 
She  should  have  observed  at  least  -0  cases  of  diabetes,  including  a 
case  of  threatened  or  actual  coma.  The  qualifications  are  many 
but  the  character  of  the  nursing  is  attractive.  It  is  true  that  the 
supply  of  such  nurses  is  seldom  equal  to  the  demand.  Several  of 
my  nurses  who  have  been  with  patients  during  preliminary  treat- 
ment have  later  gone  back  to  the  same  patients  for  a  few  days  at  a 


DIRECTIONS  FOR  NURSES  IN  CHARGE  OF  DIABETICS    477 

time,  in  order  to  instruct  them  in  the  newer  ideas  of  treatment 
which  have  arisen  in  the  interim.  A  physician  who  carries  through 
the  preliminary  treatment  of  a  case  of  diabetes  with  one  of  these 
nurses  is  really  taking  a  course  in  postgraduate  medicine,  and  more 
and  more  physicians  are  asking  for  these  nurses,  so  that  they  can 
treat  their  own  diabetic  patients  without  sending  them  to  hospitals 
or  specialists.  Such  a  nurse  pays  for  herself  by  the  saving  of 
laboratory  and  medical  fees. 

TABLE  208. — METHOD  OF  REPORTING  DIET  TO  THE  PHYSICIAN.' 
NAME  on  CASE  No....  DATE 


Food. 

Breakfast. 

Dinner. 

Supper. 

Total 
grams. 

Carbo- 
hydrate. 

Protein. 

Fat. 

5%  veg  .... 
10%  vcg  .  .  . 

100 

200 

150 

450 

15 

8 

0 

Eggs    .... 

2 

2 

12 

]2 

Meat,  cooked 
Chicken 

60 

GO 

16 

10 

Fish  

GO 

GO 

12 

Bacon  

15 

15 

30 

5 

15 

Butter 

10 

10 

10 

30 

25 

Cream,  20% 
Cream,  40% 
Oatmeal  .... 
Etc  

30 
15 

30 

30 

90 
15 

3 

's 

3 
3 

18 
1 

Totals  .  . 
Calories 

26 

4 

59 
4 

81 
9 

Total 

calories 

=  10G9 

104 

236 

729 

The  daily  duties  of  a  diabetic  nurse  are  summarized  below: 

1.  The  nurse  should  familiarize  herself  with  the  printed  matter 
which  is  given  the  patient. 

2.  The  patient  should  be  encouraged  to  write  down  all  questions 
in  a  note-book  and  the  nurse  should  keep  a  note-book  of  her  own. 

3.  The  treatment  of  diabetes  is  constantly  improving  as  it  is  in 
any  disease  where  there  is  not  an  absolute  cure,  but  the  general 
plan  of  treatment  will  not  depart  far  from   the  directions  given 
below.     The  nurse  should  understand  the  principles  of  treatment, 
for  then  she  can  take  better  care  of  the  patient  in  the  hospital  and 
what  is  more  important  train  the  patient  how  to  live  after  leaving 
the  hospital.     It  is  just  as  much  a  part  of  the  nurse's  duty  to  explain 
to  the  patient  the  details  of  the  daily  diet,  with  the  values  of  carbo- 
hydrate, protein  and  fat  allowed,  as  it  is  to  serve  the  trays.     Food 
given  to  a  patient  lasts  him  for  a  few  hours;  the  explanation  of  food 
values  lasts  for  life. 

1  Diet  cards.     Thomas  Groom  &  Co.,  Boston. 


47S  AIDS   IX    MA\A(!KMK\r   OF   DIABETIC 

4.  Collection  of  I'rlnc. — Collect  all  urine  and  preserve  in  a  bottle 
large  enough  to  hold  the  twenty-four-hour  quantity.  This  may  be 
graduated  to  •">()  cubic  centimeters.  The  urine  should  be  voided  at 
7  o'clock  each  morning  and  the  twenty-four-hour  quantity  meas- 
ured at  that  time.  Save  at  least  120  c.c.  (4  ounces)  as  a  specimen. 
Record  date  and  (ju  ntity  in  cubic  centimeters  both  upon  the 
specimen  bottle  and  chart  as  follows:  November  1(5-17,  1C>2()  c.c. 
One  ounce  may  be  considered  !>()  c.c.  (actually  2!).(>  c.c.).  Caution 
patients  to  save  the  urine  while  at  stool.  Preserve  the  urine  during 
collection  in  a  cool  place.  The  vessel  and  the  urinal  are  to  be 
thoroughly  cleaned  and  scalded  each  day.  I  rine  may  be  kept 
from  decomposition  by  placing  in  the  bottle  at  the  beginning  of 
the  day  one  teaspoonful  of  one  of  the  following  solutions:  Toluol, 
10  percent,  alcoholic  solution  of  thymol,  chloroform.1  Formalin  (10 
per  cent,  formaldehyde)  may  be  used  (5  drops  to  1000  c.c.)  if  the 
urine  is  not  to  be  tested  for  ammonia.  The  nurse  should  examine 
the  urine  daily  for  sugar  and  diacetic  acid  and  once  a  week  for 
albumin. 

">.  Wcitjhi  of  Patient. — Weigh  the  patient  daily  at  7  A.M.,  after 
the  urine  has  been  voided.  Note  weight  of  clothes.  Record  total 
weight  and  weight  of  clothes. 

(i.  Nurses  should  realize  that  the  diabetic  diet  makes  strenuous 
demands  upon  the  digestive  organs.  A  healthy  individual  could 
be  easily  upset  by  it;  if  a  diabetic  patient  is  so  upset,  serious 
consequences  may  result.  (Jive  the  patient  too  little  ratherthan 
too  much  food,  and  caution  the  patient  to  eat  slowly.  Plan  in 
advance  the  day's  diet,  so  that  suitable  quantities  of  carbohydrate, 
protein  and  fat  shall  be  distributed  between  the  three  meals. 

(a)  Record  the  character  and  quantity  of  all  food  actually  eaten. 
Remember  that  food  may  be  served  and  yet  not  eaten. 

(h)  Allow  slightly  more  carbohydrate  at  breakfast  than  at  the 
other  two  meals,  and  rather  more  protein  at  noon. 

(<•}  If  cream  is  allowed,  the  amount  for  the  day  should  be  measured 
out  before  breakfast  and  kept  in  one  receptacle  until  used. 

(d)  Five  per  cent,  vegetables  should  always  be  on  hand  and  care 
taken  to  secure  perfect  eggs. 

(e)  In  the  preparation  of  vegetables  bo  sure  they  are  thoroughly 
cleaned.     Cut    away   all   discolored   and   decayed    portions.     Only 
the   tender   portions   of  green    vegetables   should    be   served    raw. 
The  coarser  parts  may  be  cooked  in  soups.      Vegetables  should  he 
deliciously   cooked,    served    in    an    appetixmg    manner,    preferably 
as  a    puree,  and   if  allowed,   prepared    with   butter  or  cream.      A 
portion    of   the   carbohydrates   may    be   removed    by  changing   the 
water  used   in  cooking,  and   if  the  water  of  .">  per  cent,   vegetables 

-erv;it  ive,    il    iiiu>t    !><•    expelled    by    heat    before 


DIRECTIONS  FOR  NURSES  IN  CHARGE  OF  DIABETICS    479 

is  changed  three  times,  this  constitutes  "thrice-cooked  vegetables" 
(see  p.  533),  which  contain  practically  no  carbohydrate.  Two 
vegetables,  of  which  at  least  one  is  cooked,  should  be  served  at 
noon  and  night,  and  one  vegetable  at  breakfast  as  well,  if  the  diet 
is  without  bread,  oatmeal,  potato,  or  fruit. 

(/)  The  composition  of  the  meals  depends  upon  the  diet  ordered, 
but  usually  they  are  arranged  best  as  follows: 

Breakfast. — Coffee,  cream,  bacon,  an  egg.  If  fruit  is  allowed  a 
portion  of  the  twenty-four-hour  quantity  can  be  taken. 

Dinner. — Clear  soup,  n  eat  or  fish,  vegetables. 

Sn])})er. — Tea  or  cracked  cocoa,  and  a  small  portion  of  a  cooked 
vegetable,  salad,  meat  or  fish.  Never  serve  cold  meat  without  some 
hot  food.  If  fat  meat  is  served,  one  must  allow  for  it  in  reckoning 
up  the  diet. 

7.  Bowels.— The  bowels  should  move  daily;  give  an  enema  if 
necessary.     No  cathartics  should   be  given  while  fasting,   unless 
prescribed  for  the  particular  case;  at  other  times  extract  cascara 
sagrada,  1   to  5  grains  once  or  twice  daily;  aloin,  grain  -i,  or  a 
compound  rhubarb  pill;  less  frequently  Hunjadi,  Apenta  water,  a 
Seidlitz  powder  or  mineral  oil  may  be  employed  as  needed;    but 
it  should  be  remembered  that  the  sodium  bicarbonate  in  a  Seidlitz 
powder  may  lead  to  the  appearance  of  diacetic  acid  in  the  urine 
if  the  patient  has  a  low  tolerance  for  carbohydrate. 

8.  Exercise. — Exercise  should  be  moderate  at  first,   later  con- 
siderable,   and    should    always    be    taken    after    meals.     Caution 
patients  not  to  get   overtired,   but  encourage  them  to  exercise 
vigorously,  steadily  increasing  the  amount  of  exercise  to  a  point 
that  would  put  a  healthy  individual  into  splendid  physical  con- 
dition.    Patients  must  learn  to  know  that  restriction  of  exercise 
means  restriction  of  diet. 

9.  Direrbion. — Diversion    should     be    furnished    for    patients. 
Encourage  reading  aloud,  games  and  other  activities  which  will 
enable  the   patient  to  enjoy  life  with   others.     Seek   to  prevent 
worry.     Allow  no  conversation  about  the  disease  or  the  diet  after 
the  noon  meal,  and  banish  any  thought  of  invalidism.     Remember 
Eskimos  formerly  lived  on  a  diet  containing  only  about  50  grams 
carbohydrate  per  day. 

10.  If  massage,  is  given,  use  cocoa  butter  or  some  other  prepara- 
tion rich  in  fat,  alcohol  seldom  or  not  at  all  because  of  its  drying 
effect. 

11.  Instantly  report  loss  of  appetite,  nausea,  vomiting,  restless- 
ness, unusual  fatigue,  excitement,   vertigo,  headache,  drowsiness, 
listlessness,  discomfort,   painful   or  deep   breathing,   because  such 
symptoms  are  frequently  significant   of  diabetic  coma.     Neglect 
to  report  the  above  symptoms  is  inexcusable.     Note  the  rules  for 
the  treatment  of  threatening  coma  on  page  391. 


4SO  AIDS  IN   MANAGEMENT  OF  DIABETIC  CASES 

('.     TABLE  209. — DIAKKTIC   HISTORY  CHART  FOR  TIIK   I'SE  OF  INSTITUTIONS 

AND  OF  PHYSICIAN'S  ESPECIALLY  INTERESTED  IN  DIABETES.' 
NAME  AUK          M  S         RKF.  by  Du.          No.          DATK 

Yrs.          F  M 

Mo.s.  W 

ADDRESS  ADDRESS 

OCCUPATION-  RACK 

HEREDITY.       Diab.  incll.  Obesity  Gout  Tuberculosis 

F.  M.  Children 

]5ro.  Sist.  Other  relatives 

HABITS.       CJIsOII     .          Tobac.  C't'a  or  Von.  Exercise.  Sleep. 

PAST  HISTORY. 

ONSKT.       J)atc:  Acute.  Gradual.  SYMPTOMS. 

SUUAR  FIRST  DISCOVERED.  CAUSE  OF  EXAM. 

ETIOLOUY. 

a.  Obesity.  b.   Heredity.  c.   Dietary  excesses.             d.   Strenuous  life. 

e.    Xervous:  (1)  organic;   (2)  functional.         f.   Infections.         g.   Arteriosclerosis, 

h.   Syphilis.  i.  Trauma.  j.    Pancreas,  abd.  pain;             fatty  stools, 

k.  Thyroid,  size           exophth.  tremor            nervousness            palp,            vom. 

diarrhea  perspiration.  1.   Hypophysis,  aeromegaly                adolesencc 

{ii»uitisiii  dial),  insi]).  in.   Liver.             n.   Gout.             o.   Kidney. 

PREVIOUS  TREATMENT.     RESULTS — • 
SYMPTOMS  SINCE  ONSET. 


a.    Weight  :   Highest 
At.  onset 
First  visit 
Height 

Date        b.   Loss  of  strength 
c.    Polyuria 
d.   Polydipsia 
e.    Polyphagia 

f.    Pains 
g.   Extremities 
h.  Cramps 
i.    Bowels 

OTHER  SYMPTOMS. 

a.    Digestive 
c.    Renal 

b.   Circ. 
d.   Resp. 

e.   Nervous 

PRESENT  COMPLAINT. 

PHYS.    EXAM.     General  appearance  Skin  and  mucous  ineinb.  Thyroid 

Pupils  and  muscles  Eye-grounds  Glands:  C.  A.         I. 

Hearing  Breath :  acetone  Al.  air:    ('()•>  Teeth 

Pulse  Arteries  Bl.  pr.  (recumbent)  Syst .  Dias.  Apparatus 

Heart  Apex,  size  sounds 

Lungs 

Abdomen  Liver  Spleen  Kidneys 

Genitals  Hernia,  Edema  Knee-jerks 


DIRECTIONS  FOR  NURSES  IN  CHARGE  OF  DIABETICS    481 


•gjj  -uiui 

).J         'JIT!        JB[OOA[V 


•juoo 
poo[$.[ 


spunod 


•a 


•gui§  pj^oj  'uiuouuuy 


•piji:  ju.vjnq.^xo-d 


o 


31 


4S2  1//AS  L\   MAXAC-EMEXT  OF  DIABETIC  CASES 


'—          W 

o> 


W 


03 

5 


0 

P 


DIRECTIONS  FOR  NURSES  IN  CHARGE  OF  DIABETICS    483 


.3   2  ~>  "'  —  ~*  O  **       CO  iO  1C  -^       C  C  O  O       "O       CO       O 


fl  3e 

C  >•*.* 


. 


484 


AIDS  IN  MANAGEMENT  OF  DIABETIC  CASES 


E.     ACTUAL  DIETS  EMPLOYED  TO  RENDER  PATIENTS 
SUGAR-  AND  ACID-FREE. 

1.  Case  No.  92o,  male,  onset  September  1915,  at  twelve  years, 
nine  months. 

TABLE  212. — CASE  Xo.  92:?.     AGED  TWELVE  YEARS,   NINE  MONTHS. 
ONSET  SKI-TKMHEH,  1015. 


Urine. 

Diet 

in  scrams. 

Sugar. 

^ 

a 

-^ 

c                  •£ 

2 

g 

"5 

Date. 

c                  a 

~~ 

~?  ^ 

">  2. 

C               .i               'Z 

J?              d 

J?  ~ 

"*  x 

£                                                     CJ                 ; 

C                        *7* 

'C                    Q    ^ 

~?  3 

1            .3            6     .     1 

"5          o          ->; 

J2          "£  " 

J2  g 

>         3      !  £   !  £ 

U             £             £ 

u      5 

"A 

1915. 

Oct.      9 

2600           0           6.6      172 

13 

2600           0           7.7      200 

14 

Protein  -  fat  diet    with 

out  my  advice 

Entrance   to     hospital  ev 

eningof   October  15 

i 

15 

Even-  +  +  +  +    0  .  S  <     0 

- 

ing 

15    16 

200"      +  +  +        0          0 

000 

0         0 

79 

16   17 

1200         ++           0          0 

5            3            0 

32       +  5 

80 

17-18 

1150           +             0          0 

10          13     ,       5 

137      +10 

78 

18-19 

1150           +             0          0 

13          28          16 

30S       +13 

77 

19  20 

750            0              0          0 

IS           29           16 

332       +18 

76 

20  21 

1675           0             0          0 

21           31           31 

487       +21 

76 

21    22 

1525            0              0          0 

24          33          43 

605       +24 

76 

22   23 

1900            0              0           0 

38          43          66 

91  S       +3S 

76 

23   24 

1950            0              0          0 

39     '     57     '     67 

987       +39 

76 

24   25 

1700            0              0          0 

39          59           80 

1112       +39 

76 

25   26 

1950            0              0          0 

10             5             0 

60       +10 

76 

26  27 

1475                           0          0 

39           59           SO 

1  1  12       +39 

75 

27   28 

1600            0              0          (I 

40           60           94 

1246       +40 

76 

28   29 

1400            0              0          0 

17           62           95 

1291   ,    +47 

76 

1916. 

Nov.     S 

1000            0           0.2        2 

IOC 

1917. 

May  UP 

0            ...         0 

55           65           87 

1263       +55 

Observe  absence  of  aeidosis  October  !)  and  Y.\  before  treatment 
was  be»'im,  its  appearance  immediately  after  a  fat-protein  diet 
during  one  day  prescribed  without  my  knowledge  and  its  gradual 
disappearance  so  soon  as  patient  commenced  fasting.  If  the  fat- 
protein  diet  had  been  continued,  would  the  ease  have  proved  so 
benign?  (See  Tables  212  and  215.) 

'_'.  Case  Xo.  U.'iS,  male,  onset  September,  191"),  age  two  years, 
four  months;  came  under  observation  October  2">,  1915;  weight  in 

1  In  eleven  hours  to  7  A.M.,  October  16,  n<>  alkali  «iven.        -  Blood  sutrar,  0.08  per  cent. 


ACTUAL  DIETS  EMPLOYED 


485 


August,  1915,  32  pounds;   no  diabetic  heredity. 
and  210.) 


(See  Tables  213 


TABLE  213.  —  CASE  No.  938.     AGED  Two  YEARS,  FOUR  MONTHS. 
ONSET  SEPTEMBER,   1915. 


Crii 

£ 

ie. 

Diet  in 

grams. 

03 

-3 
O 

Date. 

Sugar. 

Tjj 

"cj 

0 

* 

',mill]0  \ 

•5      .    1 

s          s    I    3 
>=;           c-         o 

o 
.a 

o 

T. 
t-t 

-H"3 

•f 

1 

a 

o         s.          s.         o 

3 

1915. 

Oct.    25 
25-26' 
26-27 

175 
400 

0          7.6 
0          32 

28 
28 

+           00 

0 

0 

0             0 

0 

27-28 

275 

SI  +         0          0 

3 

4 

2           46 

+  3 

27 

28-29 

250 

+  +       0.6        1 

10 

12 

8         160 

+   9 

26 

29-30 

300 

000 

7 

3 

0           40 

+  7 

27 

30-31 

350 

000 

12 

6 

0           72 

+  12 

27 

Oct.31-Xov.  1 

150 

000 

15 

17 

5         173 

+  15 

27 

1-  2 

300 

000 

15 

20 

1  1         239 

+  15 

27 

2-  3 

150 

000 

16 

21 

17         301 

+  16 

25 

3  -  4 

200 

000 

17 

22 

23         363 

+  17 

26 

4-  5 

225 

0       :     0          0 

18 

23 

29         425 

+  18 

26 

5-  6 

300 

000 

18 

27 

35         495 

+  18 

26 

7-  8 

150 

00          0 

19 

28 

41         557 

+  19 

26 

8-  9 

200 

000 

10 

16 

21         293 

+  10 

26 

1917. 

Fob.   15-10- 

1000 

010         0 

10 

32 

43         555 

+  10 

24 

Xo  alkali  given. 

TABLE    214.  —  ABBREVIATIONS    EMPLOYED    ix    RECORDING    FOOD    UPON*    THE 

DIABETIC  CHART. 


asp. 

1m. 

bts. 

b. 

br.  sp. 

bt. 

cab. 

car. 

caul. 

ccl. 

ch. 

cl. 

cof. 

c.  j. 

c.c. 

cr. 

c.c. 

cue. 

egpt. 

fh. 

g- 


asparagus 

bacon 

beets 

broth 

Brussels  sprouts 

butter 

cabbage 

carrots 

cauliflower 

celery 

chicken 

clams 

coffee 

coffee  jelly 

cracked  cocoa 

cream 

cubic  centimeters 

cucumbers 

egg  plant 

fish 

grams 


gr.  fr. 

let. 

mt. 

mshr. 

oat. 

oin. 

or. 

ol. 

r.  o. 

oys. 

pot . 

rad. 

spin. 

sq. 

s.  b. 

s.  f.  m. 

torn. 

tur. 

veg. 

wh. 

w.  or  c. 


grapefruit 

lettuce 

meat 

mushrooms 

oatmeal 

onion 

orange 

olives 

olives  (ripe) 

oysters 

potato 

radishes 

spinach 

squash 

string  beans 

sugar-free  milk 

tomato 

turnip 

vegetable 

white 

with  (cum.) 


1  Blood  sugar,  0.17  por  cent. 


2  Blood  sugar,  0.08  per  cent. 


480 


AIDS  IX  MANAGEMENT  OF  DIABETIC  CASES 


X 


o 


H 

2  c         •_;       -w  •  -      ^  •/}  j,       a-a                H_ 

H 
^ 

cJO         -Co          a—          S"So          v?   sS 
o^          oo          C^f          K^3_3          oj    (H                      C 

< 

^           § 

5           § 

'           ~ 

•i         c 

-H 

0 

C 

- 

.. 

5 
) 

o                     '.-: 

CO                               CO 

"o                      "a 

•  -              •-                                     o                          o 

lO 

"1               " 

^     —  H                O 

•hn                            co                       c? 

m                  "3                  "3     M         •—  ! 

-i;           o_c-oo               t-                    ^ 

H                     X 

ir'   —  |          —  "  ?"l           --."  •—•"           •"-  -3                  •  -  S 

<N  ?l        01  '  •        ?>)  ?l        •-'-t              T-H  ^                   ^H 

1   ~^         ^~*    r-         '""'      •           tl      •                 tC'    ~*                        t 

~_.         ;  o       ,;  o       M  •g            MV;                6 

1 

o  —         -C^         ,          0_                or:                      CJ 

£ 

J 

o           —  "                                 —  •                c 

H  ^  a      a 


o  "^      42       o 


o  -     .  „ 

CO         —       4-  .£ 

tib"~  c 

^   <=5   C-J  •  - 


ACTUAL  DIETS  EMPLOYED 


487 


1 

G 

on 

G 

0 

O 

U3 

1?  o          §  o             6" 

•  »  r-  PO                     Tn                     to   

m       .                          •  ••  ™                        .   O 

O       . 

•*      t-                       rH         . 

..Bo      £|i> 

.  -   .  .  0 

00°^ 

^H'* 


^  a  tc 

s  o  c 


O          i— <    O  g 


S  fe  S 


^  .  s 


o    " 


^s 


48S  AIDS  IX   MAXAdEMEXT  OF  DIABETIC  CASKS 


P       s 


e 


<-  <->^    it 

??5  If 


7171  71 


ACTUAL  DIETS  EMPLOYED 


489 


3.  Case.Xo.  759,  female,  onset  of  diabetes  at  age  of  forty  years. 
Marked  diabetic  heredity.  Present  observations  made  at  age  of 
fifty-five.  Just  prior  to  first  observation  the  patient  ate  a  fat- 
protein  diet  in  order  to  make  a  favorable  impression.  Note  the 
acidosis,  its  disappearance  when  fat  was  omitted,  the  decrease  in 
the  glyeosnria,  although  the  carbohydrate  in  the  diet  remained 
essentially  unchanged,  and  that  the  patient  became  free  from 
acidosis  and  sugar  within  twenty-four  hours  of  entrance  to  the 
hospital.  Notwithstanding  that  the  patient  had  suffered  with 
heart  disease  for  years  and  had  had  attacks  of  angina  pectoris,  she 
gave  up  her  automobile  and  eventually  walked  three  and  a  half 
miles  daily  before  leaving  the  hospital.  Died  July  23,  1916.  Angina 
Pectoris.  '  (See  Tables  217  and  218.) 

TABLE  217. — CASE  Xo.  759.     WOMAN  AGED  FIFTY-FIVE  YEARS;  DURATION 
OF  DIABETES  FIFTEEN  YEARS.     (See  page  341.) 


Urine. 

Diet 

in  grains. 

"3 

I         .= 

o 

u 

e 

"3 

~ 

C 

"5 

o 

c 

5               .2 

o    ; 
-*^  i~ 

« 

>>  H        ~ 

£-3 

£ 

"5           § 

'-  3 

'u 

-3"!      - 

~z  2 

[c 

5               .2 

•C   ~» 

a 

7- 

C        's.     y. 

r~H 

1915. 

Sept.  20  27      1500  +     Ac.       +  +  +  + 

47 

little 

much 

much 

4      164J 

27-28      1200                            0 

35 

45  ± 

little 

0 

or 

none 

28-29        72 

0                           0 

14  + 

30  ± 

little 

-       0 

or 

none 

29-30      108 

0           "              0 

24 

40  ± 

little 

-       0 

or 

none 

Entran  -c    to     Xe\v    Ent: 

land 

Done  oness 

Hosp 

ital. 

Oct.       1             1100                             0 

tr. 

— 

— 

— 

.  .        0 

156? 

1-  2      1000                             + 

0 

25 

2.5 

0 

110 

+20     0  ;   155J 

2-  3      1550                           0 

0 

25 

2.5 

0 

110 

+20     0      1351- 

3-  4      1200                           0 

0 

25 

2.5 

0 

110 

+20     0  !   1551 

4-  5      1250                           0 

0 

25 

25  .  0 

17 

253 

+25     0      154^ 

5-  6      1000                           0 

0 

30 

30  .  0 

22 

402 

+30     0  ,   153^ 

0-  7      1500                           + 

0 

32 

30  .  0 

18 

410 

+32     0      1521 

7-  8      1550                           0 

0 

33 

31.0 

30 

520 

+33     0      1511 

8-  9      1500           "               + 

0 

39 

50  .  0 

2S 

008 

+39     0      152  J 

9-10      1500                           0 

0 

41 

52.0 

40 

780 

+41     0      152^ 

10-11      157 

5           "               0 

0 

42 

53  .  0 

52 

848 

+42     0  !   1521 

11-12      1200                           + 

0 

48 

54  .  0 

52 

870 

+48     0      1525 

12-13      1200                           + 

0 

4S 

54  .  0 

49 

849 

+4s     0      152  1 

13-14        80 

0                           + 

0 

55 

50  .  0 

58 

900 

+55     0      152| 

14-15      120 

0                           0 

0 

55 

50.0 

58 

900 

+55     0      1531 

20              90 

0                           0 

0 

— 

— 

— 

— 

i 

•101)  AIDS   IN   MAXAdEMKXT  OF   DIABETIC   CASKS 


- 


ACTUAL  DIETti  EMPLOYED 


491 


t£  t>         MM 


TABLE  219. — CASK  Xo.  LSI,1  ACKD  .5o  YEARS.     DURATION  OF  DIABETES,  11 
YKAKS.     MY  FIRST  CASE  OF  INTKRMITTKNT  FASTING. 


Trine. 

Diet 

in  grams. 

^ 

_  * 

c 

0- 

c 

^  "        -r 

u 

a 

t^ 

c." 

•i|ffi 

1 

c 

£     ~ 

S  t; 

>i 

>>Ss 

"o-S.2 

Date. 

c. 

-  c 

j3 

~Ji  £    ? 

~6 

si 

g 

^  ~ 

J 

'E 

_c 

o 

o 

o  a 
•£"3 

li-'^  i 

"o 

o"^  ~     .2 

_o 

.t; 

~ 

OS 

5 

03 

c 

"3 

r;  ~~ 

3  o.  a 

> 

CJ        S 

~ 

y,    <  i  ;_) 

O 

PL, 

Fn 

< 

O 

U 

* 

1915. 

Sept. 

19-20 

1800   23   +  +  +  + 

11.3 

3.7 

74 

109 

20-21 

2000   24    +  +  + 

0  .  34 

3  .  0  36 

30 

5 

0 

0 

140 

-  6 

107 

21-22 

2000 

22    +  +  + 

.  .  !  32 

30 

5 

0 

0 

140 

-  2 

108 

22-  23 

2000   .  .    +  +  + 

2  .  5  24 

20 

5 

0 

0 

100 

-  4 

106 

23-24 

2000 

+  +  +  + 

..   3.0  16 

3 

2 

0 

0 

20 

-13 

107 

24-  25 

1SOO   23   +  +  +  + 

0.34 

..   2.8  11 

0 

0 

0 

0 

0 

-11 

108 

25  26 

1800 

26   _(-  +  +  + 

8.3  3.4 

0 

0 

0 

0 

13 

91 

0 

103 

26-27 

1SOO   27    +  +  + 

.  .   2.6 

0 

0 

0 

0 

20 

140 

0 

103 

27-28 

1300   31    +  +  + 

..   2.2  21 

40 

21 

20 

264 

+  19 

104 

2s  29 

1300   32    +  + 

31 

40 

21 

20 

264 

+  9 

103 

29  30 

1300   ..     +  + 

6.5 

1.9  40 

40 

21 

20 

264 

0 

103 

Oct. 

30-  1 

1600 

+  +  + 

7.1 

2.0!  6 

0 

0 

0 

20 

140 

-  6 

106 

1-  2 

1400 

27    +  +  + 

0 

0 

0 

0 

20 

636 

0 

101 

2-  3 

1700 

+  +  + 

9.3  1.9  20 

20 

50 

24 

20 

636 

0 

103 

3-  4 

1800  i   ..    +  +  + 

9  .3  1  .  5  29 

20 

50 

24 

20 

636 

-  9 

104 

4-  5 

2250   .  .    +  +  + 

1.7  29 

20 

50 

24 

20 

618 

-  9 

106 

5-  (i 

2150   ..    +  +  + 

1.4   4 

0 

0 

0 

20 

140 

-  4 

105 

6-  7 

1400   .  .    +  +  + 

1.0   3 

0 

0 

0 

20 

140 

-  3 

105 

7-  8 

1000   ..    +  +  + 

1.4   4 

10 

50 

24 

20 

596 

+  6 

105 

8-  9 

1400   ..    +  +  + 

1.5  10 

10 

50 

24 

20 

596 

0 

105 

9-10 

1600           4-4- 

13 

10 

50 

24 

20 

596 

;.j 

104 

10-11 

1400 

+  +  + 

8 

10 

50 

24 

20 

596 

+  2 

104 

11-12 

1400 

+  +  + 

0 

0 

0 

0 

20 

140 

_  9 

104 

12  13 

1400 

+  + 

4 

10 

50 

24 

20 

596 

+  6 

104 

13-14 

1300 

+  + 

10 

50 

24 

20 

596 

+  10 

105 

14  15 

1200 

+  + 

.  . 

2 

10 

50 

24 

20 

596 

+  8 

105 

15-16 

1700 

+  + 

0 

10 

5-1 

28 

20 

64s 

+  10 

105 

16  17 

1SOO 

+  + 

7 

10 

54 

2s 

20 

6  is 

+  3 

105 

17  is 

2200 

+  + 

4 

10 

54 

2s 

20 

6  is 

+  6 

104 

18-19 

1600 

+  + 

1  .  5   0 

0 

0 

0 

20 

140 

0 

104 

19  20 

2500 

0 

.  .  i  .  . 

60 

10 

0 

20 

120  i 

20  21 

1  S50 

0 

0 

0 

28 

2s 

20 

504 

0 

105 

21  22 

1450 

..    slight  + 

0 

0 

32 

32 

20 

556 

0 

105 

22  23 

1500 

0 

0 

0 

34 

34 

20 

5S2 

0 

105 

23  21 

2050 

0 

0 

0 

34 

34 

20 

5S2 

0 

105 

24-25 

1500 

+ 

0 

0 

34 

34 

20 

5X2 

0 

105 

25  26 

1-100 

0 

0 

0 

0 

0 

20 

1-10 

0 

106 

26  27 

1500 

0 

0 

0 

•13 

36 

20 

636 

0 

106 

30-  31 

1900 

0 

0 

10 

43 

36 

20 

676 

0 

106 

31-  1 

2000   .  .      0 

0 

10 

51 

11 

10 

6S3 

0 

105 

Nov 

1   2 

SOO   .  .      0 

0 

0 

0 

5 

35 

0 

106 

2  3 

1600    .  .      0 

0 

2 

44 

40 

20 

684 

+  2 

106 

3  4 

2150 

0 

0 

0 

36 

35 

10 

529 

0 

105 

4   5 

1SOO 

0 

0 

0 

44 

40 

10 

606 

0 

105 

5  6 

1700  '   .  .      0 

0 

0 

16 

45 

10 

659 

0 

105 

6  7 

1SOO          I) 

0.  19 

.  .   .  .   o 

0 

46 

45 

10 

659 

0 

105 

7  s 

1700  :   .  .      0 

0 

0 

46 

45 

10 

059 

0 

107 

S  9 

1500   .  .      0 

0 

0 

0 

0 

10 

70 

0 

106 

21  22 

141)0   .  .      0 

0 

1 

43 

53 

10 

723 

+  i 

108 

( 402  ) 


1  See  jintic  493  and  Table  220. 


HOSPITAL   TREATMENT  493 

4.  Case  No.  LSI ,  male,  onset  in  January,  1904,  at  forty-four  years 
of  age.  February  5,  1908,  (U>  per  cent,  sugar.  Became  sugar-free 
in  March,  thereafter  sugar  usually  present  up  to  entrance  to  hos- 
pital September  19,  1915.  Patient  feeble  and  unable  to  read  at 
entrance.  Upon  discharge  could  read  a  little  and  able  to  walk 
several  miles  a  day.  Died  April,  191  (i.  Coma. 

The  reaction  of  the  urine  was  acid  throughout  and  the  albumin 
never  exceeded  a  very  slight  trace.  No  alkali  was  given  save  4  grams 
of  sodium  bicarbonate  September  20,  21,  and  22.  On  fast  days 
coft'ee,  tea  and  broths  were  given  freely.  (See  Tables  219  and  220.) 

TABLE  220. — SUMMARY  OF  DIKT  OF  CASE  No.  181.     (See  Table  219.) 

1915. 

Sept,  20,  21  5  per  cent.  veg.  300;  or.  2. 

22  5  per  cent.  vcg.  300;  or.  1. 

23  5  per  cent.  veg.  100. 

24,  25,  26  Fasting,  save  alcohol,  as  recorded  on  chart. 

27,  28,  29  5  per  cent.  veg.  300;  or.  2;  lean  mt.  GO. 

30  Fasting. 
Oct.                          1  Fasting. 

2,    3,    4  5  per  cent.  veg.  300;  or.  1;  lean  nit,  120;  eggs  2. 

5,    0  Fasting,  save  alcohol. 

7,    8,     0,  10  As  on  Oct.  2,  3,  4,  except,  orange. 

1 1  Fasting. 

12,  13,  14  As  on  Oct.  2,  3,  4,  except,  orange. 

15,  16,  17  Add  sugar-free  milk  60. 

18  Fasting. 

19  5  per  cent.  veg.  600;  or.  2;  gr.  fr.  1. 

20  5  per  cent,  veg.  300  (washed);  mt.  30;  eggs  3;  bacon  10. 

21  Idem.,  plus  sugar-free  milk  60. 
22,  23,  24  Idem.,  plus  sugar-free  milk  90. 

25       5  per  cent.  veg.  300  (washed). 
26,  27,  28       5  per  cent,  veg.  300  (washed);  mt.  30;  eggs  3;  cl.  6;  bacon 

10;  Akoll  1;  sugar-free  milk  90. 
29       5  per  cent,  veg.  (not  washed). 

31  Idem.,  except  mt.  60;  whisky  20. 

Nov.  1        Fasting  except  5  per  cent,  veg.  150  (washed);  whisky  10. 

2  5  per  cent,  veg.  300;  mt,  60;  eggs  3;  bacon  10;  cl.  6;  Akoll 

1;  sugar-free  milk  90;  whisky  40. 

3  Idem.,  except  mt,  30;  whisky  20. 

4  Idem.,  except  mt.  60. 

5,    6,     7  Idem.,  except  bacon  20. 

8  Fasting,  except  5  per  cent,  veg.  150  (washed). 

9,  10  As  on  November  4. 

11,  12,  13,  14  Idem.,  except  mt,  30. 

15  Fasting. 

16,  17  As  on  November  11. 

18,  19  Idem.,  plus  Hepco  1. 

20  Idem.,  plus  40  per  cent.  cr.  15. 

21  Idem.,  plus  40  per  cent,  cr.  30. 

F.     HOSPITAL  TREATMENT. 

More  than  once  I  have  cleared  up  the  mysterious  downward 
course  of  a  case  of  diabetes  by  sending  the  patient  to  the  hospital. 


404  AIDS   IX   MAXAGEMEXT  OF   DIABETIC   CASES 

It  is  surprising  ho\v  benign  severe  cases  of  diabetes  become  when 
under  the  physician's  eye.  On  the  other  hand,  great  caution  is 
necessary  in  the  treatment  of  severe  cases  of  diabetes  in  the  first 
few  days  following  their  entrance  to  an  institution.  Habits  of 
life  and  of  diet  are  broken,  and  the  patient  is  under  some  excite- 
ment. Formerly  coma  was  by  no  means  an  uncommon  occurrence, 
because  of  the  radical  elimination  of  carbohydrate  and  the  change 
to  an  excessive  protein-fat  diet.  Xow  all  this  is  altered.  Never- 
theless, watchful  care  over  each  patient  should  be  exercised.  Xo 
matter  how  mild  the  case,  the  patient  should  be  daily  seen  by 
the  physician  until  his  exact  condition  is  understood.  If  acidosis 
is  present,  two,  three,  or  four  visits  should  be  made  during  the 
twenty-four  hours.  I$y  this  means  I  believe  I  have  more  than  once 
averted  a  threatening  coma.  I  have'  gradually  acquired  so  much 
confidence  in  the  methods  of  treatment  outlined  on  pages  oOf)  and 
/>S7  that  I  find  hospital  patients  require  far  less  attention.  The 
patient's  routine  should  be  disturbed  as  little  as  possible.  Entrance 
to  a  hospital  by  no  means  eliminates  his  going  outdoors.  It  is  quite 
as  harmful  to  rest  too  much  as  too  little.  The  utmost  simplicity  of 
diet  should  be  maintained.  A  complete  physical  examination  of 
the  patient  should  be  made  just  prior  to  his  discharge. 

The  first  specimen  of  urine  voided  by  the  patient  on  entrance 
to  the  hospital  gives  little  indication  of  his  true  condition.  It  is 
the  rule  to  find  that  diabetic  patients  have  made  violent  alterations 
in  their  diet  in  the  fc\v  days  preceding  entrance.  They  have  either 
broken  all  dietetic  rules  which  they  may  have  previously  followed 
with  considerable  care,  fearing  that  their  diet  is  to  be  curtailed, 
or,  in  order  to  make  a  favorable  impression  upon  the  physician, 
may  have  lived  upon  a  far  more  rigid  diet  than  that  to  which  they 
have  been  accustomed.  This  was  well  illustrated  by  case  Xo.  7."><). 
This  patient  had  been  free  from  acidosis  for  a  considerable  length 
of  time,  but,  prior  to  her  first  visit  to  me,  a  diabetic  relative  had 
suggested  restriction  of  diet,  and  this  resulted  in  the  appearance  of 
a  four-plus  diacetic  acid  reaction.  That  this  was  but  temporary 
was  shown  by  its  prompt  disappearance  when  fat  was  withdrawn 
from  the  diet.  Table  21  7. 

I  lospital  treatment  is  desirable  for  the  untreated  case  of  diabetes, 
because  it  gives  him  a  liberal  dietetic  education.  I  Ic  really  is  attend- 
ing school  and  acquiring  knowledge  which  will  be  of  value  to  him 
for  the  rest  of  his  life.  He  learns  from  association  with  other 
patients,  observes  their  mistakes  and  discloses  his  own.  He  gains 
confidence  because  he  can  observe  the  condition  of  patients  as  they 
leave  the  hospital  and  can  compare  it  with  his  own  upon  entrance 
and  \vit  h  that  of  others  who  conic  later.  lie  learns  what  the  mean- 
ing of  suu'iM'  in  the  urine  is  and  how  to  test  his  urine.  He  has 


HOSPITAL  TREATMENT  495 

illustrated  before  him  methods  which  will  enable  other  patients 
and  himself  to  become  sugar-free,  and,  what  is  more  important, 
becomes  thoroughly  familiar  with  what  to  do  when  sugar  returns. 
The  diet,  which  formerly  was  obscure,  becomes  simple,  and  he 
appreciates  the  reasons  for  its  restrictions. 

Hospital  treatment  is  desirable  because  it  affords  the  usually 
tired  diabetic  patient  freedom  from  worry,  and  even  if  his  diet  were 
unchanged,  such  a  respite  would  be  helpful.  During  the  last  year, 
and  particularly  since  the  newer  ideas  about  the  desirability  of 
exercise  have  been  introduced,  the  spirit  pervading  the  hospital 
has  changed.  The  prevailing  attitude  is  one  of  cooperation  and 
mutual  helpfulness.  Each  patient  is  expected  to  teach  someone 
else,  and  from  each  patient,  as  he  comes  in,  the  older  patients  expect 
to  learn  something  which  will  benefit  their  particular  case.  It  is 
advantageous  to  have  some  diabetic  patients  who  are  really  very 
ill.  I  quite  appreciate  the  help  in  the  management  of  patients 
which  1  have  received  from  having  such  come  for  treatment,  having 
been  told  by  others  that  they  were  past  hope. 

Hospital  treatment  is  actually  dangerous  for  the  diabetic  patient 
if  the  nurses  are  not  conversant  with  the  details  and  execution  of 
the  diabetic  diet.  This  is  now  obviated  to  a  considerable  extent 
because  physicians  give  more  precise  directions.  Formerly  it  was 
about  as  hazardous  to  the  patient  to  have  a  nurse  without  diabetic 
training  supervise  his  diet  as  it  would  be  to  be  etherized  by  a  nurse 
without  experience  in  the  use  of  anesthetics.  Excellent  nurses 
make  grave  errors  in  the  treatment  of  diabetic  patients.  It  is  sur- 
prising how  often  nurses  who  have  been  trained  in  the  foremost 
hospitals  err  in  saving  and  measuring  the  urine  and  in  carrying  out 
dietetic  orders.  Of  course,  the  physician  is  responsible  for  the 
nurses'  mistakes  in  large  share.  Nevertheless,  it  is  notable  how 
poorly  a  diabetic  patient  gets  on  with  some  nurses  and  how  well 
with  others.  After  having  had  the  same  head  nurses  for  months  in 
charge  of  the  diabetic  patients  at  the  New  England  Deaconess 
Hospital  and  Corey  Hill  Hospital,  I  wonder  how  the  patients  man- 
aged to  get  along  as  well  as  they  did  under  the  old  regimen.  Coma 
ceases  to  exist  as  an  emergency  when  the  patient  is  under  the 
charge  of  a  trained  diabetic  nurse.  The  labor  entailed  in  educating 
a  diabetic  nurse  in  a  hospital  where  diabetes  is  rarely  treated  is  far 
more  than  that  required  to  teach  the  patient.  The  patient  has 
the  diabetes — not  the  nurse — and  is  consequently  the  one  most 
interested.  Furthermore,  the  patient  is  aided  in  the  treatment 
by  his  own  feelings  and  can  communicate  these  to  the  physician. 
In  a  hospital  he  often  neglects  to  do  this  because  he  trusts  to  the 
nurse  and  often  believes  that  whatever  is  done  is  all  right  and  thus 
neglects  to  discuss  questions  which  come  up. 


490  AIDS  L\   MANAGEMENT  OF  DIABETIC  CASES 

Hospital  treatment  fails  of  its  purpose  unless  the  patient  is  dis- 
charged to  the  care  of  his  physician  at  home  with  a  report  of  his 
condition  while  at  the  hospital  and  with  recommendations  for  future 
care.  This  entails  much  labor,  which  at  times  may  not  he  appre- 
ciated by  either  patient  or  physician,  but  it  is  a  duty  which  the 
hospital  doctor  should  never  neglect.  It  has  been  my  custom  on 
Tuesdays  and  Fridays  at  nine  o'clock,  to  give  a  clinic  at  the  hospital 
for  the  benefit  of  the  patients,  their  physicians,  nurses  and  relatives. 
Every  effort  should  be  made  to  interest  the  family  physician  in  the 
care  of  the  case,  and  the  directions  given  the  patient  should  be  in 
such  form  that  a  busy  practitioner  can  readily  acquaint  himself  not 
only  with  what  has  been  done,  but  how  he  should  proceed. 

The  management  of  diabetic  patients  in  many  large  hospitals  is 
an  example  of  inefficiency.  Instead  of  having  the  diabetic  patients 
grouped  together  where  the  diets  could  be  easily  supervised,  they 
are  often  scattered  throughout  many  wards.  If  the  patients 
were  assembled,  labor  in  the  kitchen,  labor  in  nursing,  and  labor 
on  the  part  of  house  officers  and  attending  physicians  would  be 
saved.  Furthermore,  the  patients  would  get  far  better  treatment 
if  they  could  be  under  the  charge  of  a  head  nurse  thoroughly  skilled 
in  their  care,  instead  of  having  a  nurse  who  had  had  only  a  few 
diabetic  patients  in  her  two  or  three  years  of  training.  Two 
anesthetists  in  the  Mayo  Clinic  at  Rochester  have  held  their  posi- 
tions for  twelve  and  thirteen  years  respectively.  Hospital  superin- 
tendents and  physicians,  in  their  search  for  efficiency,  should  profit 
from  this  example.  Each  hospital  nurse  during  her  course  of  hos- 
pital training  should  eat  at  a  metabolism  table  for  one  week,  weigh 
all  her  food  and  calculate  the  carbohydrate,  protein,  fat  and  calories 
in  her  diet.  A  diabetic  patient  is  likely  to  progress  far  less  rapidly 
on  the  road  to  health  in  a  ward  with  twenty  to  forty  other  patients, 
which  is  attended  by  three  to  five  nurses  with  varying  periods  of  duty 
and  no  special  nurse1  responsible  for  any  special  case,  than  under  the 
efficient  supervision  of  a  head  nurse  trained  in  the  management  of 
diabetics.  Furthermore,  association  of  one  diabetic  patient  with 
another  diabetic  patient  is  of  mutual  advantage.  In  one  large  hospital 
where  I  was  asked  to  prepare  a  diabetic  patient  for  a  laparotomy, 
nine  different  nurses,  all  without  adequate  diabetic  training,  cared 
for  the  patient  during  the  twenty-four  hours  preceding,  during  and 
after  the  surgical  operation,  and  this  was  notwithstanding  the  fact 
that  the  administrative  head  of  the  hospital  meant  to  cooperate 
with  me.  A  little  rearrangement  of  hospital  routine  would  save 
hospitals  in  the  aggregate  many  thousands  of  dollars. 

('.  II.  Mayo'  has  emphasized  the  importance  of  efficiency  in  the 

1  Modern  Hospital,  I'.ll-l,  iii,  p.  L'l.">. 


HOSPITAL   TREATMENT  497 

hospital  treatment  of  cases.  The  stay  of  cases  of  appendicitis  in 
the  Mayo  Clinic  has  been  reduced  to  about  one  week;  so  short  a  stay 
is  not  desirable  in  diabetes,  but  by  full  and  constant  instruction  of 
patients  and  their  relatives,  the  hospital  period  could  be  greatly 
shortened  and  patients  will  be  more  inclined  to  return  after  a  few 
months  to  learn  new  methods  of  treatment  and  to  assure  themselves 
that  they  are  following  a  proper  course. 

The  annoyances  from  diabetic  patients  breaking  the  diet  in 
open  wards  are  now  practically  abolished.  All  patients  are  expected 
to  have  the  urine  free  from  sugar.  It  does  not  take  long  for  the 
patient  to  learn  that  although  he  may  "cheat  the  doctor,  he  cannot 
cheat  the  disease."  When  one  of  my  sugar-free  diabetic  patients 
carelessly  ate  figs,  fasting  followed  automatically  until  his  urine 
again  became  sugar-free.  Furthermore,  as  I  had  taken  the  trouble 
to  get  him  sugar-free  the  first  time,  I  told  him  it  was  unnecessary 
for  me  to  do  so  a  second  time,  and  as  his  eyesight  did  not  allow  him 
to  do  his  own  Benedict  test,  a  friendly  diabetic  neighbor  performed 
this  for  him. 

Thymol  is  probably  the  best  antiseptic  to  use  in  preserving 
urinary  specimens,  but  its  expense  makes  it  unsatisfactory.  Chloro- 
form Avorks  well,  but  the  chloroform  must  be  expelled  by  heat 
before  testing  for  sugar,  as  it  gives  a  positive  reduction  test  with 
Benedict's  and  Fehling's  methods.  Frequently  no  antiseptic  is 
required  if  the  specimens  are  simply  kept  in  a  cool  place,  and 
particularly  is  this  true  if  the  bottles  are  sterilized.  This  is  easily 
done  with  steam  by  the  use  of  a  wash  boiler  in  which  only  a  little 
water  is  needed.  Next  to  chloroform  as  a  preservative  is  toluol. 
Sufficient  should  be  used  to  make  a  layer  on  top  of  the  specimen. 
Formalin  (40  per  cent,  formaldehyde)  may  be  employed  (5  drops 
to  1000  c.c.),  but  if  used  it  makes  determinations  of  ammonia 
untrustworthy.  All  specimen  bottles  should  be  tightly  corked. 

Cheap  bottles  for  collecting  the  urine  are  easily  obtained.  It  is 
desirable  that  they  be  wide-mouthed  so  that  they  can  be  readily 
cleansed.  The  attractive  percolator  bottles  graduated  to  50  c.c. 
and  of  2000  and  4000  c.c.  capacity  cost  about  one  dollar  apiece  if 
bought  by  the  dozen.  Candy  bottles  of  similar  size  can  be  obtained 
from  drug  stores,  and  these  have  the  advantage  also  of  glass  stop- 
pers. Such  bottles  can  be  graduated  by  the  use  of  diamond  ink. 

The  collection  of  urine  is  simplified  if  bottles  of  this  type  are 
employed.  Labor  expended  in  measuring  the  urines  of  ten  diabetic- 
patients  with  a  500  c.c.  graduate  is  considerable.  This  is  wholly 
obviated  by  the  employment  of  the  large  graduated  bottles,  by 
which  the  accurate  pouring  of  small  quantities  of  urine  is  avoided. 

The  method  of  multiple  examinations  of  urine  for  sugar  has  been 
described  on  page  177.  By  this  means  ten  urines  are  examined  in 
32 


1<)S  AIDS  IX   MANAGEMENT  OF   DIABETIC   CASKS 

about  the  same  length  of  time  as  it  formerly  took  to  examine  a  single 
specimen. 

The  weight  of  the  patient  recorded  in  terms  of  the  naked  weight 
should  he  taken  daily  at  the  same  morning  hour. 

The  diabetic  diet  in  a  hospital  is  simple.  Emphasis  should  be 
placed  upon  the  point  that  the  patient  shall  be  taught  the  value 
of  each  portion  of  food  he  receives.  It  may  be  easier  for  the  hospital 
dietitian  to  have  the  physician  specify  the  grams  of  carbohydrate, 
protein  and  fat  which  the  patient  is  to  have,  but  in  so  doing  the 
doctor  fails  to  treat  his  patients  unless  the  nurses  explain  the 
quantity  of  carbohydrate,  protein  and  fat  in  each  different  article 
of  food.  From  the  first  day  of  entrance  to  the  hospital  the  patient 
should  begin  to  learn  his  diet,  and  unless  his  food  is  given  to  him 
in  forms  which  he  can  easily  duplicate  upon  leaving  the  institu- 
tion, his  hospital  stay  is  a  failure.  Almost  anybody  can  get  a  dia- 
betic patient  sugar-free,  but  the  education  of  the  patient  to  care 
for  himself  upon  leaving  the  hospital  constitutes  more  than  90  per 
cent,  of  the  treatment. 

Simplification  in  weighing  food  is  accomplished  by  the  use  of 
scales1  of 500  grams  capacity  with  a  movable  dial  which  can  be  set  at 
xero  when  an  empty  dish  is  placed  upon  them.  Food  can  then  be 
placed  in  the  dish  and  the  weight  instantly  read  off.  Such  scales 
reduce  the  labor  of  weighing  fully  90  per  cent,  as  compared  with 
scales  where  weights  must  be  added  to  a  pan  or  lever.  Dietetic 
prescriptions  should  be  given  in  simple  form.  These  are  illustrated 
by  the  tables  on  pages  :]()(»,  308,  :>09,  4S(>,  4SS,  490,  and  5:55. 
In  the  kitchen  the  diet  for  each  patient  can  be  written  by  the 
nurse  with  pencil  on  cheap  paper  blocks  twenty  by  thirty  inches  in 
sixe.  These  are  visible  at  some  distance,  so  that  the  nurses  actu- 
ally in  charge  of  patients  can  fill  the  orders  by  glancing  at  the  chart 
while  about  their  work.  Furthermore,  it  is  easy  to  keep  such  slips 
for  reference  and  by  this  means  improvements  in  the  diet  can  be 
made. 

A  diabetic  patient,  upon  entrance  to  a  hospital,  should  be  made 
to  understand  that  he  is  taking  a  course  in  diabetes.  For  successful 
graduation  in  the  course  it  is  understood  that  he  shall  he  able: 

( 1 )  To  demonstrate  ho\v  to  test  a  urine  for  sugar. 

(2)  To  serve  himself  with  approximate  accuracy,  without  scales, 
75  grams  of  a  5  per  cent,  vegetable. 

C!)  To  record  a  summary  of  his  diet  for  the  previous  day. 

(4)  To  explain  the  quantity  of  carbohydrate  which  it  contains. 

(5)  To  state  his  diet  on  his  weekly  fast  day. 

((})  To  describe  what  he  is  to  do  if  sugar  returns  in  the  urine. 

1  John  Chatillon  &  Sons,  New  York. 


II OS  PI  TA  L   TREA  TMEN  T 


499 


THE   DIET  OF  TEN  PATIENTS   FOR  A   DAY  AT  THE   NEW 

ENGLAND   DEACONESS   HOSPITAL,  JANUARY  23,  1916, 

DISPLAYED   IN   THE   KITCHEN   FOR  THE 

GUIDANCE  OF   NURSES. 


BREAKFAST,  JANUARY  23,  1916. 1 


Name. 

Bacon. 

Eggs 

Bal.     . 

2 

Cleve. 

'.     45 

2 

Hoy.    .      . 

1 

John    . 

Keif     .      . 

'.     20 

1 

Leff.    .      . 

McN. 

20 

2 

Drap. 

.      20 

1 

Tier     . 

.     30 

2 

Vegetables, 

5  per  cent.      Butter. 


200 
100 


50 

100 
100 
100 


10 
10 


10 

10 
10 
10 


Cream. 

10 
30 
15 

10 

30 
30 
10 


Orange. 


0.1 


DINNER,  JANUARY  23,  1916. 


Name. 

Meat. 

Bal.     . 

.       120 

Cleve. 

Drap. 

60 

Hoy.    . 

.         60 

John    . 

Keif.    . 

!       60 

Leff.    . 

McN. 

60 

Tier.    . 

.       60 

Eggs. 


Vegetables. 


o'o- 

200 

100 
100 

50 

50 

50 

200 


150 


75 
75 
75 


Butter. 
10 

10 


10 

10 
10 


Cream. 

30 

45 
30 

30 

45 
10 


Orange. 

0.5 

0.5 
0.4 


Extra. 
Bran 
Bran 
Lister 

Bran 

Bran 
Bran 
Bran 


Extra. 

Lister 

Bran 
Bran 

Bran 


Strawberries,  75  g. 
Lister 


SUPPER,  JANUARY  23,  1916. 


Name. 


Bal.     . 
Cleve. 
Drap. 
Hoy.    . 
John    . 
Keif.    . 
Leff.    . 
McN. 
Tier. 


Meat. 

6  oysters 

90 

60 
6  oysters 

60 

60 
60 


Eggs. 
1 
1 


Vegetables. 

5  per  cent.     Butter.     Cream.     Orange. 


200 
100 
200 
250 

150 
150 
150 
150 


10 

5 

10 

10 

10 

10 
10 


15 
45 
45 
15 

15 

15 
10 


Extra. 

Lister 

Lister 
Lister 

Lister 
Lister 


Several  years  ago  the  hospital  class  system  for  diabetic  patients 
was  employed  by  Dr.  Mosenthal  at  the  Vanderbilt  Clinic  in  Xew 
York  City;  shortly  afterward  it  was  adopted  by  my  former  assistants, 
H.  W.  Goodall  at  the  Boston  Dispensary,  and  by  F.  G.  Brigham  at 
the  Massachusetts  General  Hospital,  where  his  diabetic  clinic  now 
includes  275  patients.  Goodall2  has  found  the  results  most  striking. 
He  attributes  much  of  his  success  to  the  painstaking  work  of  his 
secretary-chemist,  who  has  had  immediate  supervision  of  the  cases. 


1  The  weights  are  in  grams. 

2  Goodall:  Boston  Med.  and  Surg.  Jour.,  1916,  clxxv,  p.  156. 


AIDS  I.\   MANAGEMENT  OF  DIABETIC  CASES 

A  special  feature  of  the  work  has  been  the  instruction  of  the  members 
of  the  household  responsible  for  the  diet.  Mosenthal1  has  described 
the  system  he  inaugurated  and  pointed  out  how  it  may  serve  to 
familiarize  physicians  with  the  treatment  of  diabetes,  aid  in  the 
instruction  of  students  and  improve  the  treatment  of  patients.  lie 
calls  attention  to  the  necessity  of  limiting  the  number  of  patients  in 
such  a  clinic  in  the  same  way  hospitals  limit  the  number  of  admis- 
sions to  the  wards.  The  usefulness  of  this  method  of  instruction 
of  patients  is  obvious.  Each  patient  acquires  a  knowledge  of  the 
disease  by  coming  in  contact  with  many  other  cases,  and  he  is  sure 
to  disseminate  his  knowledge. 

G.     AMBULATORY  TREATMENT. 

Most  diabetic  patients  in  the  past  have  been  treated  in  physi- 
cians' offices,  and  most  diabetic  patients  in  the  future  will  con- 
tinue to  be  treated  in  the  same  manner.  It  is  perfectly  possible  to 
carry  out  good  treatment  under  these  circumstsnces,  but  it  involves 
great  patience,  much  time  in  the  education  of  the  patients,  and  thus 
necessarily  expense.  It  is  advantageous  in  that  the  habits  of  the 
patients  are  little  changed,  the  whole  responsibility  is  placed  upon 
the  patient,  and  from  the  start  the  diabetic  treatment  is  made 
to  fit  into  the  routine  of  life.  The  danger  of  this  method  is  chiefly 
that  the  patient  is  not  seen  frequently  enough  at  the  very  begin- 
ning of  treatment,  and  with  the  alteration  of  diet  there  is  a  possibility 
of  acidosis.  With  modern  treatment,  especially  with  the  omission 
of  fat  from  the  diet  for  the  first  days,  this  danger  is  greatly  lessened, 
and  I  see  no  reason  why  treatment  of  this  character  should  not  be 
maintained  if  physicians  and  patients  so  desire.  (See  Case  No. 
12:>7,  p.  o()(i,  as  an  illustration  of  how  simple  the  dietetic  part  of 
such  treatment  may  be  made.) 

The  same  routine  as  that  carried  out  at  the  hospital  should  be 
taught  the  patient.  In  general,  he  should  be  made  conversant 
with  the  rules  embodied  in  A  of  this  section.  Much  time  will  be 
saved  if  the  patient  is  accurately  taught  at  the  start  how  to  save 
the  urine,  to  measure  the  food,  and  to  record  it  neatly  and  in  a 
systematic  manner  so  that  the  physician  can  quickly  detect  mistakes 
in  the  diet.  Under  no  condition  allow  the  patient  to  tell  what  he 
has  eaten,  but  insist  on  his  presenting  a  dietary  record.  The  urine 
should  be  examined  and  reported  upon  while  the  patient  is  in  the 
office1,  for  unless  this  is  done  the  patient  is  apt  to  feel,  and  he  has 
a  right  to  do,  so  that  he  is  not  getting  satisfactory  and  prompt 
treatment.  Intil  a  patient  has  been  free  from  sugar  and  acid  for 

1  Mosenthal:    Medical  Record,  1015,  Ixxxviii,  p.  589. 


AMBULATORY   TREATMENT 


501 


o 

g 

S 
- 
o 
u 
a 
tf 
a 

S3 
El 

a 

S3 

H 


5j 

•- 


o 

B 

u 

p 
^ 

o 
U 

« 

2 
O 

« 


•J3SUO  JO 


•JISIA  }S[ 


•ojnssdjd-poojy 
•asinj 


'A\  'IV  'S 


•xaS 


'•"-'<>  A 


i.2^       'qjuoj\: 

.—    :t   ri      "~ 

C  =2  'J^A 


fa 
•< 

a 
^ 

S5 

a 
S 

^H 

O 

a 

PH 

T 


502  AIDS  IN   MANAGEMENT  OF  DIABETIC  CASES 

at  least  a  week,  lie  should  report  daily  to  the  physician  in  person 
or  by  telephone. 

Most  of  my  cases  in  the  past  have  been  treated  as  ambulatory 
patients.  This  was  far  more  difficult  under  the  older  methods  of 
treatment  than  today.  With  a  fairly  intelligent  patient  in  a  single 
visit  the  history  can  be  taken,  physical  examination  made,  the  prin- 
ciples of  treatment  explained  and  instruction  given  in  the  use  of  the 
Benedict  test.  Under  favorable  conditions  it  is  then  possible  for  a 
patient  to  attend  to  some  of  his  routine  work,  become  sugar-free  and 
present  himself  for  a  second  visit  after  a  few  days.  Whereas  it  is 
seldom  possible  to  accomplish  as  much  at  a  single  visit,  it  does 
show  the  contrast  in  the  expense  of  treatment  for  a  patient  under 
the  old  and  new  regimen. 


SECTION   VTI. 
FOODS  AND  THEIR  COMPOSITION. 

A.     DIABETIC  FOODS. 

THE  improvement  in  the  treatment  of  diabetes  owes  mtieh  to 
the  recent  dissemination  of  knowledge  regarding  the  composition 
of  foods.  To  the  United  States  Government  we  are  indebted 
for  an  excellent  monograph  by  Atwater  and  Bryant  entitled  "The 
Chemical  Composition  of  American  Food  Materials,  Bulletin  No. 
28,  Revised  Edition,"  which  was  first  issued  in  1906.  This  can  be 
purchased  by  sending  ten  cents  in  coin  to  the  Superintendent  of 
Documents,  Washington,  I).  (1.  From  this  I  have  abstracted  such 
analyses  as  are  especially  useful  in  computing  the  diets  of  both 
normal  and  diabetic  individuals  and  have  computed  the  calories 
per  100  grams  instead  of  recording  the  same  per  pound. 

The  State  of  Connecticut,  from  its  Agricultural  Experiment 
Station  in  New  Haven,  has  also  published  excellent  special  reports 
on  diabetic  foods,  and  from  year  to  year  adds  analyses  of  new 
preparations.  So  far  these  have  been  distributed  upon  request. 
Nearly  all  of  the  analyses  in  these  reports  will  be  found  to  have 
been  incorporated  in  my  tables,  because  they  are  of  so  much  practical 
value.  For  ready  consultation  I  have  inserted  lists  of  foods  often 
used  by  diabetic  patients,  with  their  carbohydrate  content,  which 
also  appear  in  the  Connecticut  reports,  although  some  of  these 
analyses  exist  in  somewhat  different  form  in  the  Government 
tables.  To  these  latter  lists  have  been  added  the  values  of  protein 
and  fat  as  well. 

Whereas  the  analyses  of  many  so-called  diabetic  foods  are 
recorded,  no  special  food  is  recommended.  Each  physician  must 
decide  the  merits  of  any  particular  food  for  himself. 

The  medical  profession  is  under  great  obligation  to  the  Connec- 
ticut Agricultural  Experiment  Station  for  having  provided  for 
work  of  this  character,  and  I  regret  very  deeply  that  the  apprecia- 
tion of  physicians  and  diabetic  patients  cannot  be  shown  in  some 
tangible  way.  I  am  also  personally  indebted  to  Professor  John 

(503) 


504  FOODS  AND   THEIR  COMPOSITION 

Phillips  Street,  who  carried  out  these  investigations,  for  furnishing 
me  much  helpful  information  on  many  topics  relating  to  diabetic 
foods  and  for  constructive  criticism  in  the  practical  treatment  of 
my  cases. 

ll'haf  /.s1  a  Diabetic  Food? — The  definition  of  a  "diabetic"  food 
formulated  by  the  Joint  Committee  on  Definitions  and  Standards 
is  as  follows: 

"Diabetic  Food. — Although  most  foods  may  be  suitable  under 
certain  conditions  for  the  use  of  persons  suffering  from  diabetes, 
the  term  'diabetic'  as  applied  to  food  indicates  a  considerable 
lessening  of  the  carbohydrates  found  in  ordinary  products  of  the 
same  class,  and  this  belief  is  fostered  by  many  manufacturers  on 
their  labels  and  in  their  advertising  literature.  A  'diabetic'  food 
contains  not  more  than  half  as  much  glycogenic  carbohydrates  as 
the  normal  food  of  the  same  class.  Any  statement  on  the  label 
which  gives  the  impression  that  any  single  food  in  unlimited  quan- 
tity is  suitable  for  the  diabetic  patient  is  false  and  misleading." 

Professor  Street  very  properly  lays  down  the  following  detailed 
requirements  which  a  diabetic  food  should  fulfil: 

1.  It  should  contain  very  much  less  carbohydrate  than  found 
in  a  normal  food  of  the  same  class — certainly  not  over  half  as  much. 

2.  The  label  should  bear  a  correct  statement  of  the  percentages 
of  protein,  fat,  and  carbohydrate  present. 

0.  The  amounts  of  the  different   carbohydrates  present  should 
be  declared  on  the  label,  /.  e.,  starch,  sucrose,  levulose,  lactose,  etc. 

1.  The  processes  of  manufacture  should  be  so  standardized  that 
uniformity  of  composition,  within  reasonable  limits,  will  be  main- 
tained from  year  to  year. 

f).  Xo  statement  should  be  placed  on  the  label  which  would  give 
the  impression  that  any  food  in  unlimited  quantity  is  suitable  for 
a  diabetic;  patient. 

(').  In  the  advertisements  of  these  foods  emphasis  should  be  put  on 
the  carbohydrate  content  rather  than  on  the  amount  of  protein 
present. 

The  narrow  confines  of  the  diabetic  diet  have  greatly  stimulated 
the  manufacture  of  so-called  diabetic  foods.  These  are  often 
serviceable,  but  are  to  be  employed  with  discretion.  Their  use 
should  be  discouraged  at  the  beginning  of  treatment.  The  patient 
should  never  become  dependent  upon  special  diabetic  foods,  for 
they  are  often  unobtainable,  always  make  him  conspicuous,  and 
when  he  acquires  a  disgust  for  foods  of  this  class  it  is  all  the  harder 
to  abide  by  the  original  diet,  \\heu  the  patient  buys  one  of  these 
foods,  unfortunately  he  is  often  given  a  list  of  other  diabetic  foods 
and  a  new  diabetic  diet  list,  and  confusion  in  the  diet  often  results. 
The  patients  under  my  care  who  have  done  best  either  never  use 


DIABETIC  FOODS  505 

special  diabetic  foods  or  only  a  few  varieties,  such  as  Akoll  Biscuits, 
Barker's  Gluten  Flour,  Casoid  Flour,  Ilepco  Flour,  Lister  Flour, 
No.  1  Proto  Putt's,  and  Sugar-free  Milk. 

The  user  of  diabetic  foods  should  also  remember  that  such  foods 
may  serve  two  distinct  purposes:  (1)  as  an  aid  in  determining 
the  diabetic's  tolerance  for  carbohydrates,  and  (2)  when  such  a 
tolerance  is  determined,  as  a  source  of  supply  of  food  containing 
reduced  amounts  of  carbohydrates  and  suited  to  the  individual 
patient's  use.  Diabetic  foods  of  the  first  class  should  be  as  near 
carbohydrate-free  as  possible;  foods  of  the  second  class  may  con- 
tain considerable  amounts  of  carbohydrates  and  still  be  useful  for 
the  diabetic.  It  is  apparent,  however,  that  it  is  the  province  of 
the  physician,  not  of  the  patient,  to  determine  this  tolerance;  and, 
furthermore,  it  is  evident  from  the  analyses  that  the  mere  calling 
a  product  a  "diabetic  food"  by  no  means  establishes  its  right  to 
such  a  name  or  its  usefulness  to  the  diabetic.  Foods  containing  60 
or  70  per  cent,  of  carbohydrates  are  no  more  "diabetic  foods"  than 
potatoes,  rice,  or  oatmeal,  and  are  no  more  entitled  to  that  name. 

1.  Substitutes  for  Bread. — Many  of  the  preparations  upon  the 
market  contain  as  great,  or  even  a  greater,  quantity  of  carbohydrates 
than  ordinary  bread ;  a  few  contain  less ;  but  the  percentage  of  carbo- 
hydrate may  vary  from  time  to  time.  Patients,  and  sometimes 
physicians,  forget  that  substitutes  for  bread  must  be  prescribed  only 
in  definite  amounts.  A  diabetic  bread  should  never  be  prescribed 
without  a  knowledge  of  its  content  of  carbohydrate,  protein,  and  fat. 

The  bread  of  one  of  the  largest  bakeries  in  Boston,  upon  analysis, 
showed  55  per  cent,  carbohydrate.  Bread  made  without  milk  or 
sugar,  but  with  water  and  butter,  contains  45  to  50  per  cent,  carbo- 
hydrates. Such  a  bread  is  undoubtedly  superior  to  many  different 
bread  substitutes  upon  the  market.  The  percentage  of  carbohydrate 
in  toast  is  greater  than  in  plain  bread  because  it  contains  less  water. 
Some  of  the  coarser  kinds  of  bread,  such  as  rye  bread,  graham 
bread,  black  bread  and  pumpernickel,  contain  somewhat  less  carbo- 
hydrate. Never  give  bread  substitutes  early  in  treatment.  Teach 
patients  to  live  without  them. 

There  are  four  types  of  bread  substitutes. 

(a)  Bran  Bread. — Bran  is  being  more  and  more  employed  in  the 
diet  of  diabetic  patients.  This  is  neither  more  nor  less  than  the  use 
of  cellulose,  and  this  is  supposed  to  have  no  effect  upon  the  metab- 
olism. Unfortunately,  the  availability  of  the  protein,  fat  and 
carbohydrate  of  wheat  bran  to  the  diabetic  patient  has  not  been 
determined,  although  there  are  plenty  of  data  upon  its  digestibility 
by  ruminant  animals.  Bread  made  of  bran  alone  is  not  very  palat- 
able, though  with  the  fat  of  bacon  or  butter  it  is  liked  better.  It 
furnishes  bulk  and  acts  favorably  upon  constipation.  If  made  with 


.")()( i  FOODS   AND   THEIR   COMPOSITION 

eggs  and  butter  tlie  flavor  is  improved.  Tt  sliould  be  remembered 
that  bran  often  contains  a  considerable  quantity  of  starch.  For  this 
reason  bran  biscuits  often  prove  to  be  a  delusion  and  a  snare  and  I 
dread  to  see  them  on  a  patient's  tray.  In  large  hospitals  where 
diabetic  patients  are  constantly  being  treated  the  danger  is  less,  for 
the  bran  is  bought  by  the  same  person  and  at  the  same  place,  but  in 
private  practice  this  is  different.  In  purchasing  bran  go  to  a  feed 
store  and  ask  for  coarse  bran  for  cattle  and  not  for  bran  for  the 
table.  The.  various  preparations  of  bran,  bran  breads,  and  cookies 
sold  under  trade  names  often  contain  carbohydrate  other  than  bran, 
hence  the  reason  for  their  palatable  taste;  beware  of  them!  They 
may  contain  over  00  per  cent,  carbohydrate,  of  which  less  than  10 
per  cent,  is  real  bran.  Mild  diabetics  get  into  little  trouble  with 
bran,  but  the  serious  ones  often  suffer.  The  starch  may  be  washed 
out  with  water  by  tying  the  bran  in  cheesecloth  and  fastening  the 
same  on  a  faucet.  It  should  be  thoroughly  mixed  and  kneaded 
from  time  to  time  to  be  sure  the  water  reaches  all  portions  and 
should  be  washed  until  the  water  comes  away  clear.  This  may 
require  an  hour.1 

(b)  Gluten  Breads. — '\  hese  breads  are  made  by  removing  the  sugar- 
forming  material  from  the  flour.  It  is  surprising  how  thoroughly 
this  can  be  done.  I  have  often  found  the  percentage  of  carbo- 
hydrate in  one  such  flour  to  be  negligible.  The  large  quantity  of 
protein  in  small  bulk  which  they  contain  is  objectionable. 

((•}  Light  Breads. — French  bread  cut  in  thin  slices  is  often  useful, 
because  it  is  bulky,  gives  the  appearance  of  a  large  quantity,  and 
carries  much  butter.  Manufacturers  have  taken  advantage  of  this 
idea,  and  many  light  breads  are  on  the  market.  These  breads 
often  contain  about  the  same  quantity  of  carbohydrate  as  ordinary 
bread,  though  a  few  contain  considerably  less.  Their  virtue  often 
consists  solely  in  their  bulk,  which  allows  a  surface  on  which  to 
spread  butter.  I  seldom  advise  breads.  It  is  better  for  the  patient 
to  forget  the  taste. 

(d)  Various  other  substances  have  been  used  for  Hour  in  the  manu- 
facture of  bread.  Thus,  aleuronat  meal  has  been  employed,  and 
with  it  have  been  mixed  various  vegetable  products.  A  group  of 
casein  breads  is  upon  the  market  in  the  form  of  casoid  flour  and 
Lister's  Diabetic  Flour,  and  to  some  diabetics  these  are  valuable. 

Soya  bean  is  also  extensively  used,  and  probably  deserves  a  still 
wider  introduction  into  the  diabetic  diet.  The  carbohydrate  in  it  is 

'Four  preliminary  analyses  of  washed  bran  showed  the  following  percentages  of 
starch:  (Mi,  l.S,  '2.7,  ~>.'2  per  cent.  Two  preliminary  analyses  showed  pentosan  '_".). s. " 
!•>:•>. .">.  The  wide  variations  in  the  percentages  of  starch  will  account  for  the  occa- 
sional occurrence  of  suszar  in  the  urine  following  the  use  of  bran  cakes.  I  hope  these 
invest  Stations  will  be  continued  in  the  laboratory  from  which  1  obtained  these 
analyses,. 


DIABETIC  FOODS  507 

unassimilable.  It  is  used  in  the  manufacture  of  Ilepco  Flour.  Agar 
agar  may  be  used  to  dilute  the  flour  or  to  add  to  bran  and  also  to  re- 
lieve the  constipation  of  thediabetic,  which  is  frequently  troublesome.1 

2.  Substitutes  for  Milk. — A  few  tablespoonfuls  of  cream  are  a 
great  comfort  to  a  diabetic  patient.  Except  in  cases  with  a  very 
low  tolerance  a  gill  (120  c.c.)  of  20  per  cent,  cream  can  generally 
be  allowed,  and  if  it  is  desirable  to  give  more  fat  without  increasing 
carbohydrate  and  protein,  a  gill  of  40  per  cent,  cream  is  also  well 
borne.  Formerly  patients  took  half  a  pint  of  40  per  cent,  cream 
readily.  With  severe  cases  it  is  seldom  possible  to  allow  more  than 
GO  to  90  c.c.  of  20  per  cent,  cream,  for  the  balance  of  the  fat  which 
can  be  safely  employed  can  more  advantageously  be  taken  in 
meat,  butter,  oil,  and  cheese.  On  the  other  hand,  fat  having  been 
removed  the  chief  value  of  the  milk  to  the  diabetic  patient  is  lost. 
The  percentage  of  sugar  in  sour  milk  is  not  much  less  than  in  fresh 
milk.  Recently,  sugar-free  milks2  have  been  put  upon  the  market 
on  a  large  scale,  and  many  of  my  patients,  particularly  children, 
have  found  them  of  distinct  advantage.  These  preparations  of 
diabetic  milk  will  keep  from  one  to  three  weeks,  and  are  conse- 
quently of  great  value  to  patients  when  traveling.  As  a  rule  they 
are  concentrated  one-half.  Consequently  they  should  be  diluted 
before  being  used.  They  are  so  valuable  for  diabetic  patients  that 
I  always  encourage  their  use  in  small  quantities  at  first,  so  that  the 
patient  can  become  accustomed  to  the  artificial  taste  and  can  deter- 
mine the  form  in  which  the  milk  is  most  agreeable  to  him.  This 
is  often  as  equal  parts  of  milk  and  Celestins  Vichy. 

Williamson3  suggested  the  following  rule  for  the  manufacture  of 
artificial  milk:  "To  about  a  pint  of  water,  placed  in  a  large  drink- 
ing pot  or  tall  vessel,  three  or  four  tablespoonfuls  of  fresh  cream 
are  added  and  well  mixed.  The  mixture  is  allowed  to  stand  from 
twelve  to  twenty-four  hours,  when  most  of  the  fatty  matter  of  the 
cream  floats  to  the  top;  it  can  be  skimmed  off  with  a  teaspoon 
easily,  and  upon  examination  it  will  be  found  practically  free  from 
sugar.  This  fatty  matter  thus  separated  is  placed  in  a  glass.  The 
white  of  an  egg  is  added  to  it  and  the  mixture  well  stirred.  Then 
dilute  with  water  until  a  liquid  is  obtained  which  has  the  exact 
color  and  consistency  of  ordinary  milk.  If  a  little  salt  and  a  trace 
of  saccharin  be  added,  a  palatable  drink,  practically  free  from 
milk  sugar,  is  produced,  which  has  almost  the  same  taste  as  milk, 
and  which  contains  a  large  amount  of  fatty  material.  With  very 
little  practice  the  right  proportions  can  be  easily  guessed,  and  of 

1  See  page  531. 

2  D.  Whiting  &  Sons,  Boston. 

3  Williamson:  Diabetes   Mellitus  and  its  Treatment,   The  Marmillan    Company, 
1898,  p.  334. 


508  FOODS  AND   THEIR  COMPOSITION 

course  much  larger  quantities  can  be  employed,  in  order  to  prepare 
a  considerable  amount  of  the  drink  at  one  time,  than  those  men- 
tioned above." 

Rennet  may  be  made  from  milk,  but  unless  the  curd  is  carefully 
washed  it  will  contain  2  to  2.5  per  cent,  lactose.  When  the  rennet  is 
made  from  cream  the  lactose  is  materially  diminished.  Kefir  contains 
approximately  2.4  per  cent,  milk  sugar.  Von  Noorden  says  this  milk 
has  been  of  great  help  in  the  treatment  of  diabetes  in  children. 

Lawrence  Litchfield,  of  Pittsburgh,  gives  whipped  cream  to  his 
patients  made  according  to  the  following  rule:  Add  two  ounces  of 
40  per  cent,  cream  to  a  pint  of  cold  wrater  in  a  Mason  jar  and  have 
it  shaken  vigorously  until  the  cream  is  thoroughly  "whipped." 
Sometimes  a  trace  of  saccharin  is  added,  usually  not.  "My 
patients  like  to  eat  this  with  a  spoon,  but,  of  course,  it  can  be  used 
in  any  way  that  is  desired.  It  contains  only  a  trace  of  sugar." 

The  fermented  milks  contain  about  half  as  much  carbohydrate 
as  ordinary  milk. 

B.     COMPOSITION  OF  AMERICAN  FOOD  MATERIALS.1 

In  Table  222  I  have  abstracted  from  the  Government  Publication 
of  similar  name  the  analyses  of  typical  foods.  These  data,  taken  in 
connection  with  Table  223,  will  enable  patient  and  physician  to 
make  substitutions  in  the  simple  diet  scheme  shown  in  Tables  120 
and  124. 

TABLE  222. 


Protein, 
per  cent. 

Fat, 
per  cent. 

Total             Caloric 
carbo-              value 
hydrates,        per  100 
per  cent.         Kranis. 

Bocf,  cooked: 

Roast       

22 

.3 

28.6 

356 

Round  steak,  fnt  removed        .... 

27 

.6 

7.7 

1S5 

Beef,  canned: 

I  )ricd  beef 

'-to 

2 

5.4 

211 

Beef,  corned  and  pickled: 

(  'orned  heef  ,  all  analyses    

1.5 

.(•> 

20  .  2 

307 

Mutton,  cooked: 

Mutton,  leg  roast    

25 

0 

22  .  0 

312 

Pork,  pickled,  .salted  and  smoked: 

Ham,  smoked,  lean        

19 

8 

20.8 

274 

Bacon,  smoked,  all  analyses     .... 

10 

5 

04.8 

045 

Sausage,  A  : 

Frankfort       

19 

0 

18.6 

1  .  1              25S 

Pork 

13 

0 

44  .  2 

1  .  1               468 

Deerfoot  Farm,  cooked,  analysis  furnished 

by  the  manufacturers      

19 

.  9:5 

54.21 

0.34 

Poultry  and  name,  fresh: 

Chicken,  broilers      

21 

.  5 

2.5 

111 

Fowls                     ........ 

19 

,3 

10.3 

230 

Cioose,  young      

16 

,3 

30  .  2 

403 

Turkey     

21 

1 

22  .  9 

299 

'Bulletin  No.  28,  U.  S.  Dcpt.  Agriculture,  1906.      This  can  be  obtained  by  send- 
ing 10  cents  in  coin  to  the  Superintendent  of  Documents,  Washington,  D.  (,'. 


COMPOSITION  OF  AMERICAN  FOOD  MATERIALS        509 


TABLE  222.— (Continued). 


Total 

Caloric 

carbo- 

value 

Protein, 

Fat, 

hydrates, 

per  100 

per  cent. 

per  cent. 

per  cent. 

grams. 

Beef  liver    

.       .       21.0 

4.5 

1.7 

133 

Chicken  liver,  as  purchased  . 

.      .     22.4 

4.2 

2.4 

141 

Goose  liver,  as  purchased 

.      .      16.6 

15.9 

3.7 

231 

Mutton  liver,  as  purchased    . 

.      .      23  .  1 

9.0 

5.0 

199 

Pork  liver,  as  purchased  .... 

.      .      21.3 

4.5 

1.4 

135 

Turkey  liver,  as  purchased     . 

.      .      22.9 

5.2 

0.6 

144 

Veal  liver,  as  purchased    .... 

.      .      19.0 

5.3 

127 

Fish,  fresh: 

Cod,  sections      

.      .      16.7 

0.3 

72 

Flounder,  whole       

.      .      14.2 

0.6 

04 

Haddock,  entrails  removed 

.      .      17.2 

0.3 

74 

Halibut,  steaks  or  sections 

.      .      18.6 

5.2 

124 

Mackerel,  whole       

.      .      18.7 

7.1 

142 

Salmon,  whole    

.      .      22.0 

12.8 

209 

Shad,  whole         

.      .      18.8 

9.5 

105 

Trout  (brook),  whole     .... 

.      .      19.2 

2.1 

98 

Fish,  preserved  and  canned: 

Cod,  salt,  "boneless"    .... 

.      .      27.3 

0.3 

108 

Herring,  smoked      

.      .      36  .  9 

15.8 

298 

Sardines,  canned      

.      .      23.0 

19.7 

277 

Shellfish,  etc.,  fresh: 

Clams   long  in  shell      .... 

.      .        8  6 

1.0 

2.0 

53 

Crabs,  hardshell,  whole 

.      .      10  .  6 

2.0 

1.2 

91 

Lobster,  whole   

.      .      16.4 

1.8 

0.4 

86 

Mussels,  in  shell       

.      .        8.7 

1.1 

4.1 

63 

Oysters,  in  shell        

.       .        6.2 

1.2 

3.7 

52 

Scallops,  as  purchased 

.      .      14.8 

0.1 

3.4 

70 

Terrapin        

.      .      21.2 

3.5 

120 

Turtle,  green,  whole      .... 

.      .      19.8 

0.5 

86 

Gelatin1       

.       .      91.4 

0.1 

375 

Eggs,  edible  portion:2 

Hens',  uncooked       

.      .      13.4 

10.5 

158 

Hens',  boiled       

.      .      13.2 

12.0 

168 

Hens',  boiled  whites      .... 

.      .      12.3 

0.2 

55 

Hens',  boiled  yolks         .... 

.      .      15.7 

33.3 

376 

Dairy  products,  etc.  : 

Butter                         

.      .        1.0 

85.0 

793 

Cheese,  American,  pale 

.      .      28  .  8 

35.9 

0.33 

452 

Cheese,  American,  red 

.      .      29.6 

38.3 

476 

Cheese,  cottage        

.      .      20.9 

1.0 

4.3 

112 

Cheese,  Dutch    

17.7 

316 

Cheese,  full  cream   

.       .      25.9 

33.7 

2.4 

429 

Cheese,  Limburger         .... 

.      .      23  .  0 

29.4 

0.4 

369 

Cheese,  Neufchatel        .... 

.       .      18.7 

27.4 

1.5 

337 

Cheese    pineapple    

,       .      29  .  9 

38.9 

2.6 

494 

Cheese,  Roquefort  

.      .      22.6 

29.5 

1.8 

374 

Cheese,  skimmed  milk 

.       .      31.5 

16.4 

2.2 

290 

Cheese,  Swiss      

.       .      27  .  6 

34.9 

1.3 

442 

Koumiss        

.      .        2.8 

2.1 

5.4 

53 

1  I  \inderstand  many  of  the  brands  of  commercial  gelatin  contain  from  S3  to  S7 
per  cent,  gelatin,  11  to  14  per  cent,  of  moisture  and  1  to  2  per  cent,  of  ash. — E.  P.  J. 

2  One  egg  contains  approximately  protein  G  grams  and  fat  6  grams,  of  which  one- 
half  the  protein  and  all  the  fat  are  in  the  yolk. — E.  P.  J. 

3  Estimated.— E.  P.  J. 


510 


FOODS  AND   THEIR  COMPOSITION 


TABLE  222.— (Continued) . 


Total 

Caloric 

carbo- 

value 

Protein, 

Fat, 

hydrates. 

per  100 

Dairy  products,  etc.: 

per  cent. 

per  eont. 

per  cent. 

grams. 

Milk,  condensed  .sweetened     .... 

8.8 

8.3 

54  .  1 

334 

Milk,   condensed,   unsweetened,   "evapo- 

rated cream  "          .       . 

9.6 

9.3 

Ho 

1  TO 

Milk,  .skimmed    .              . 

3.4 

0.3 

.  £ 

5.1 

1  /^ 

37 

Buttermilk    . 

3.0 

0  5 

1     Si 

o/> 

Milk,  whole 

3.3 

4  0 

^t  .  o 
r»    fl 

oo 

—  o 

Cream 

3.5 

40  0 

o  .  u 

•t   n 

/  2 

*-JWA 

Flours,  meals,  etc.: 

o  .  u 

OtM) 

Barley  meal  and  flour    . 

10.5 

2.2 

79    Q 

^A1 

Buckwheat  flour       

0.4 

1.2 

t  £t  .  o 

77.9 

OOl 

356 

Cornmeal,  unbolted      .... 

8.4 

4.7 

74  0 

'^Wl 

Hominy  

8.3 

0.6 

79  0 

Ool 
OftO 

Oatmeal  .... 

16.1 

7  2 

P,7    '-. 

oOo 
1  no 

Rolled  oats    .... 

10.7 

7.3 

\j  t   .  O 

66  2 

*tuy 

J.H7 

Rice    

8.0 

0.3 

79.0 

T:U  / 

359 

Rice,  boiled  

2.8 

0.1 

24.4 

112 

Rye  flour       

0.8 

0.9 

78.7 

359 

Wheat  flour,  California  fine      .... 

7.9 

1.4 

76.4 

358 

Wheat  flour,  entire  wheat 

13  8 

1  .9 

71    0 

^CiQ 

Wheat   flour,  patent    roller  process,   high 

t  i  .  j 

ouy 

grade  (average  of  all  analyses  of  high 

and    medium    grades    and    grade    not 

indicated)         . 

11.4 

1.0 

75.1 

363 

Wheat  preparations: 

Macaroni  .             ....... 

13.4 

0.9 

74.1 

366 

Macaroni,  cooked       ...... 

3.0 

1.5 

15.8 

91 

Bread,  crackers,  pastry,  etc.: 

Bread,  brown      

5.4 

1.8 

47.1 

231 

Bread,  corn  (Johnnycake)  

7.9 

4.7 

46  .  3 

265 

Bread,  rye     

9.0 

0.0 

53  .  2 

260 

Graham  bread    ...                   ... 

8.9 

1.8 

52  .  1 

266 

Rolls,  French      

8.5 

2.5 

55.7 

286 

Rolls,  all  analyses    

8.9 

4.1 

56  .  7 

307 

Toasted  bread     

11.5 

1.6 

61.2 

312 

White  bread,  home-made   

9.1 

1.6 

53  .  3 

270 

White  bread,  miscellaneous 

9.3 

1.2 

52  .  7 

266 

Zwieback     

9.8 

9  .  9 

73  .  5 

433 

Crackers: 

Boston  (split)  crackers        

11.0 

8.5 

71  .1 

415 

I'needa  biscuit1         

10.1 

8.8 

70.0 

399 

Graham  crackers      

10.0 

9.4 

73.8 

430 

Pilot  bread    

11.1 

5.0 

74.2 

396 

Saltines         

10.6 

12.7 

ON.  5 

441 

Doughnuts         

0.7 

21.0 

53  .  1 

440 

Pie,  apple    .... 

3.1 

9.8 

42.8 

279 

Custard    

4.2 

0  .  3 

26  .  1 

183 

Squash      .... 

4.4 

8.4 

21  .7 

185 

Pickles,  condiments,  etc.: 

(  Hives,  green-      

2.14 

12.9 

1.8 

137 

(  Hives,  ripe    

2.0 

21.0 

4.0 

220 

Peppers  i  paprica),  green,  dried 

1  5  .  5 

s  .  5 

63.0 

400 

Banana:-,  yellow     .       . 

1.3 

(>.(i 

22.0 

101 

1  Analysis  from  Conn.  Kxp.  Sta.  Report,  1914,  p.  230.     One  biscuit  weighs  7  grams 
and  contains  about  ~>  grams  carbohydrate,  0.7  gram  protein  and  0.5  gram  fat. 

2  Univ.  California  College  Agriculture,  1916.  Personal  communication. 


FOODS  AND   THEIR  CARBOHYDRATE  CONTENT 


TABLK  222.— (Continued). 


511 


Total 
carbo- 

Caloric 
value 

Protein. 

Fat, 

hydrates, 

per  100 

per  cent. 

PIT  cent. 

per  cent. 

grains. 

Nuts: 

Almonds         

21.0 

54  .  9 

17.3 

667 

Brazil        

17.0 

66.8 

7.0 

364 

Butternuts    

27.9 

61.2 

3.5 

95 

C  'host  nuts,  fresh       

G.2 

5.4 

42  .  1 

248 

Coeoanuts     

5.7 

50  .  G 

27  .  9 

607 

Filberts                 . 

15.  G 

G5  .  3 

13.0 

724 

Hickory  nuts      

15.4 

67.4 

11.4 

736 

Peanuts   

25.8 

38.  G 

24  .4 

563 

Pecans     

11.0 

71.2 

13.3 

760 

Pino  nuts*  pignolias 

33  9 

49.4 

6.9 

626 

Pistachios,  first  quality,  shelled     . 

22.3 

54.0 

16.3 

659 

Walnuts,  California       

IS.  4 

G4.4 

13.0 

726 

Walnuts,  California,  black       .       .       .       . 

27.  G 

56  .  3 

11.7 

683 

Walnuts,  California,  soft  shell 

16.6 

63.4 

16.1 

723 

Miscellaneous: 

Chocolate      

12.9 

48.7 

30  .  3 

629 

Cocoa       

21.6 

28.9 

37.7 

510 

Coroal  coffee  infusion   (1   part   boiled  in 

20  parts  water)     

0.2 

1.4 

7 

Soups  : 

Home-made  : 

Beef      

4.4 

0.4 

1.1 

26 

Bean    

3.2 

1.4 

9.4 

Go 

Chicken     

10.5 

0.8 

2.4 

61 

Clam  chowder      

1.8 

0.8 

6.7 

43 

4.G 

4.3 

5  .  5 

81 

Canned: 

Bouillon    

2.2 

0.1 

0.2 

11 

3  8 

0.9 

4.7 

43 

Chicken  soup        ....... 

3  6 

0.1 

1  .5 

22 

Consomme      .      .             

2.5 

0.4 

12 

Julienne     

2.7 

0.5 

13 

Mock  turtle    

5.2 

0.9 

2.8 

41 

3  7 

0.  1 

5.7 

40 

Oxtail         

4.0 

1.3 

4.3 

46 

Pea.  soup    ......... 

3  G 

0.7 

7.G 

52 

Tomato  soup         

1.8 

1.1 

5.G 

41 

Vegetable        

2.9 

0.5 

14 

For  analyses  of  vegetables  see  pages  200 

and  513. 

C.     FOODS  AND  THEIR  CARBOHYDRATE  CONTENT. 

(See  Connecticut  Agricultural  Experiment  Station  Report  for  1913,  Part  I.) 

The  basis  for  Table  223,  "Foods  and  Their  Carbohydrate  Con- 
tent," was  originally  printed  in  the  Connecticut  Agricultural  Experi- 
ment Nation  Report  for  1913.  That  report,  however,  gave  the 
values  for  carbohydrate  alone.  Patients  and  physicians  have  found 
the  table  most  useful,  but  in  order  to  increase  its  worth,  through 
the  help  of  Professor  Street  the  values  for  protein  and  fat  are  now 
added. 


512  FOODS  AND   THEIR  COMPOSITION 

TABLE  223.  Carho. 

Protein,  Fat,  hydrates, 

I'OOD.                                 ANIMAL    PRODUCTS.                      percent.  percent.  percent. 

All  ordinary  meats,  poultry  and  game  (except  those 

specified) .  .  0 

Brains,  bone  marrow,  pig's  feet,  gelatin,  sweetbreads, 

tongue,  eggs,  beef  juice  and  true  meat  extract       ...  .  .  0 
Camembert,   Cheddar,   Edam,    Minister,    Roquefort 

and  Swiss  cheese .  .  .  0 

Tripe,  dried  beef  and  beef  kidneys .  .  Trace 

Bologna  sausage (range  0.2  -3  . 1)      IS. 7  17.0  0.0 

Pork  sausage (range  0 . 0-8 . 6)      13. S  14.2  1.4 

Beef  liver 20.7  4.5  1.5 

Neufehatel  cheese 18.7  27.4  1.5 

Kephir 3.1  2.0  1.0 

Skimmed  milk  cheese      ....    (range  0.0-9.0)     31.5  10.4  2.0 

Full  cream  cheese (range  1 . 1-4.0)     25.9  33.7  2.3 

Chicken  liver 22 . 4  4.2  2.4 

Pineapple  cheese 29.9  3S.9  2.0 

Frankfort  sausage (range  0 . 0-0 . 0)      19.0  18.0  3.4 

Cream 2.5  IS. 5  4.5 

Sheep  liver 23 . 1  9.0  5.0 

Whey 1.0  0.3  5.0 

Calf's  foot  jelly 4.3  0.0  17.0 

FISH  AND  SHELL  FISH. 

All  common  varieties  except  those  specified    .....  .  .  0 

Canned  shrimp  and  lobster .  .  Trace 

Crayfish 10.0  0.5  1.0 

Shad  roc 20 . 9  3  .  8  2.0 

Scallops (range  1.1-6.0)      14.8  0.1  3.4 

Clams,  round 8.0  0.8  4.7 

Sturgeon  caviare 30.0  19.7  8.0 

OILS  AND  FATS. 
Butter,  lard,  tallow,  oleomargarine,  cod-liver  oil,  olive 

oil  and  other  edible  oils  (crisco,  oleo.1 — E.  P.  J.)   ...  .  .  0 

CEHEALS  (WHOLE  GRAINS). 

Buckwheat 10.1  2.5  01.0 

Millet 10.3  3.0  OS.O 

Oats,  hulled 10.2  7.0  09.0 

Corn  (maize) 9.1  4.1  09.0 

Barley S.5  1.1  70.0 

Wheat 10. >  1.7  71.0 

Rye 10.2  1.7  72.0 

Rice,  hulled 8.0  2.0  77.0 

Rice,  polished 7.1  0.3  79.0 

FLOUUS,   MEALS,   ETC. 

Soy-bean  meal 42.5  19.9  34.0 

Pea  Hour 25.7  1.8  57.0 

Acorn  meal 7.3  4.9  04.0 

Craham  flour 13.3  2.2  70.0 

Kafir-corn  Hour 0.0  3.S  70.0 

Prepared  wheat  flour 10.2  1.2  73.0 

Self-raising  buckwheat  flour 9.2  1.2  73.0 

Pup  corn,  popped 10.7  5.0  77.0 

Cassava  meal 1.3  1.2  Sl.O 

Polato  starch 0.9  0.1  Sl.O 

Sago  starch .       .        2.2  0.0  Sl.O 

Tapioca  (Arrowroot) 0.1  0.1  S4.0 

1  If  these  two  preparations  arc  estimated  as  butter  the  error  will  be  slight.— E.  P.  J. 


FOODS  AND   THEIR  CARBOHYDRATE  CONTENT 


513 


TABLE  223.— (Continued). 

Protein, 
FOOD.  PASTES.  percent. 

Banana  flour 3.9 

Corn  starch 1.2 

Noodles 13.3 

Vermicelli 10.9 

Spaghetti 12.1 

CEREAL  BREAKFAST  FOODS. 

Rolled  oats 16.7 

"Holland  Rusk" 12.1 

"Ralston  Health  Food" 11.9 

"Quaker  Wheat  Berries" 13.8 

"Wheat  let" 12.8 

"Force" 10.6 

Cracked  wheat 11.1 

"Pettijohn's  Breakfast  Food" 9.1 

"Malt  Breakfast  Food" 13.8 

"Cream  of  Wheat  " 11.5 

"Triscuit" 11.0 

"Grape  Xuts" 11. 


"Zest" 
Farina 
"  Wheatena" 


9.0 
11.0 
11.3 


A.STRY. 

33.6 


"Mapl-Flake" 11.0 

"Shredded  Wheat  Biscuit"1 8.3 

Hominy 7.6 

Puffed  rice 6.7 

Toasted  corn  flakes 

BREAD,  CRACKERS  AND  P. 

Peanut  bread 

Acorn  bread    

Cassava  bread 

Peanut  zwieback 

Whole  rye  bread 

Mince  pie (range  30.0-44.0) 

Apple  pic 

Corn  bread      

Brown  bread 

Whole  wheat  bread 

Graham  bread 

Doughnuts (range  45.0-63.0) 

Rye  bread 

Wheat  bread 

Rolls 

Toasted  bread 

Cake  (except  fruit  cake)       .      .      (range  53 . 0-78 . 0) 

Jumbles (range  52.0-71 .0) 

Alfalfa  bread 

Fruit  cake 

Macaroons (range  57 .0-70.0) 

Crackers (range  63  .0-M  .0) 


1.0 

0.0 
0.8 
2.0 
0.4 


7.3 
5.1 
1.7 
1.9 

1.6 
1.1 
1.7 
2.0 
1.5 
0.9 
1.4 
0.6 
1.2 
1.4 
2.8 
1.4 
0.6 
0.2 
0.4 


12.8 


8.0 
0 . 6 

12.3 
9.8 
4.7 
1.8 
0.9 
1.8 

21.0 
0.6 
1.3 
4.1 
1.6 
9.0 

13.5 
1.3 

10.9 

15.2 
8.8 


Carbo- 
hydrates, 
per  cent. 

85.0 
85.0 
72.0 
72.0 
74.0 


64 . 0 
72.0 
72.0 
72.0 
74.0 
74.0 
74.0 
74.0 
75.0 
75.0 
75.0 
75.0 
75.0 
75.0 
76.0 
76.0 
76.0 
78.0 
80.0 
81.0 


20.0 
27.0 
27.0 
28 . 0 
35 . 0 
38.0 
43.0 
46.0 
47.0 
49 . 0 
51.0 
52.0 
53 . 0 
53 . 0 
56.0 
61.0 
63.0 
63 . 0 
64 . 0 
64 . 0 
64 . 0 
71.0 


FRESH  VEGETABLES. 

Lettuce 1.2  0.3  2.2 

Cucumbers 0.8  0.2  2.3 

Spinach 2.1  0.3  2.3 

Asparagus 1.8  0.2  2.4 

1  Weight  of  one  biscuit,  30  grams,  and  it  contains,  approximately,  carbohydrate  23 
grams  and  protein  3  grams. 
33 


FOODS  AM)   THEIR   COMPOSITION 

TAISLK  223. — (Continued'. 


Oarho- 

FOOD.      FKKSII  VEOK 

TAKI.KS.  —  Cont  imied. 

1'rotcin, 
i)er  cent. 

Pat, 

per  cent. 

liydnitos, 
per  cent. 

Rhubarb    

0.6 

0.7 

2  .  5 

Kndive       

1.0 

0.0 

2.0 

Vegetable  marrow 

0.1 

0.2 

2.6 

Sorrel   

3.0 

Sauerkraut       .... 

1.7 

0.5 

3.0 

Beet  greens,  cooked  . 

2   2 

3  .  4 

3.2 

(  'elery  

0.9 

0.1 

3.3 

Tomatoes 

0.9 

0.4 

3.3 

Brussels  sprouts   . 

1  .0 

0.  1 

3.4 

Watercress        .... 

0.7 

0  .  "> 

3.7 

Sea-kale     

1.4 

0.0 

3.S 

Okra     

1.6 

0.2 

4.0 

<  'auliflower     .... 

1.8 

0.5 

4.3 

Kgg  j)l:int        .... 

1.2 

0.3 

4.3 

0     0   ">) 

1    (i 

0  3 

4   7 

Kadishes    

(range    2 

'.7-  7.5) 

1.3 

0.1 

5  .  0 

Leeks   

1.0 

0.4 

6.0 

Mushrooms'    .... 

(range    2. 

0    1S.O) 

3  .  :> 

0.4 

6.0 

Pumpkins        .... 

(range    3 

0-14.0) 

1.0 

0.1 

6.0 

String  beans    . 

(range    3. 

o  lo.O) 

2.3 

0.3 

6.0 

Turnips      

(range    2 

3    1S.O) 

1  .3 

0.2 

6.0 

Celery  root      .... 

6.3 

Kohl-rabi  ... 

(range    3 

5-14.0) 

2.0 

0.1 

7.0 

Oyster  ))lanl   .... 

1.2 

0.1 

7.0 

Rutabagas       .... 

(range    3  . 

0    12.0) 

1  .3 

0.2 

7.0 

TruHles      

0.1 

0.5 

7.0 

Squash       

(range    3  . 

0    lo.O) 

1  .1 

0.5 

S.O 

Heels    

(range     (i. 

0    10.0) 

1  .(I 

0.1 

9.0 

Carrots       

(range     ">  . 

0   11.")) 

1.1 

0.4 

9.0 

Onions        

(range    4. 

0    14.0) 

1.6 

0.3 

9.0 

Parsnips    

(range    (>. 

0-14.0) 

1.6 

0.5 

11.0 

Chicory 

15.0 

Peas      .       .       . 

7.0 

0.5 

15.0 

Artichokes2      .... 

2.0 

0.2 

16.0 

^  ains   

1(>  0 

Corn     

3.  1 

1.1 

1  «.).() 

Potatoes     

(range  13. 

0  27.0) 

•>  ^ 

1.1 

20.0 

Lima  beans      .... 

7.  1 

0.7 

22.0 

Sweet  potatoes 

(range  10. 

5  4-1..  r>) 

1  .S 

0.7 

20  .  0 

Soy  beans        .... 

(range  10. 

3   30.0) 

2S.O 

DUIKD   V  i-;<;i- 

:TAHU:S. 

Beans  

22  .  ") 

1.8 

.r)f).0 

(  'ow  peas  

21  .1 

1  .4 

55.0 

Peas      

21  .(i 

1  .0 

5S  .  0 

Lentils        

2.")  .  7 

1  .0 

59.0 

Lima  beans 

is.  1 

1  .5 

6«.0 

Beans,  haricots  verts 

Asparagus         

Brussels  sprouts 

Okra 

Tomatoes 

String  beans    .  .... 

'The  carbohydrate  which  the<e  contain  is  to  a  considerable  extent  unassimilable, 
and  pat  ients  olten  eat  these  wilh  impunity,  as  1  have  found  since  my  attention  was 
called  to  this  fact  by  Professor  Wardall. 

-French  artichokes.  According  to  Konig,  canned  artichokes  contain  '.(2. Hi  per 
cent,  water,  0.70  per  cent,  protein,  0.02  per  cent,  fat,  1.13  per  cent,  carbohydrates. 


FOODS  AND   THEIR  CARBOHYDRATE  CONTENT         515 

TABLE  223.— (Continued). 

Carbo- 

Protoin,  Fat,  hydrates, 

FOOD.     CANNED  VEGETABLES. — Cont'd.               per  cent.        per  pent.  per  cent. 

Maeedoine,  mixed  vegetables    .      (range    1.9-5.0)  1.4  0.0  3.9 

Artichokes (range    3.2-6.1)  0.8  0.0  4.4 

Pumpkins (range    3.6-  7.3)  0.8  0.2  6.0 

Peas (range    4.3-17.2)  3.6  0.2  10.0 

Squash (range    3.6-12.8)  0.9  0.5  10.0 

Beans,  haricots  flageolets     .      .      (range    9.8-12.4)  4.6  0.1  11.0 

Lima  beans (range    9.6-16.5)  4.0  0.3  13.0 

Baked  beans         6.9  2.5  17.0 

Red  kidney  beans 7.0  0.2  17.0 

Corn (range  11.7-25.1)  2.8  1.2  18.0 

Succotash (range  13.9-21.3)  3.6  1.0  18.0 

PICKLES  AND  CONDIMENTS. 

Distilled  vinegar 0  0  0 

Cider  vinegar1 0  0  0 . 25 

Cucumber  pickles 0.5  0.3  2.7 

Olives,  ripe 1.7  25 . 9  4.3 

Capers 3.2  0.5  5.0 

Prepared  mustard 4.7  4.1  5.0 

plus  cereal    .      (range    4.0-15.0)  3.5  1.9  7.0 

Ketchup (range    3.0-20.0)  1.8  0.2  10.0 

Spiced  salad  vinegar              10.0 

Horseradish    ....             1.4  0.2  11.0 

Chili  sauce (range  14.0-28.0)  20.9 

Spiced  pickles 0.4  0.1  21.0 

FRUITS  AND  BERRIES. 

Strawberries 1.0  0.6  5.0 

Grapefruit .  .  .  .  6.0 

Alligator  pear .  .  .  .  7.0 

Lemons ,  1.0  0.9  7.0 

Watermelons ,  0.3  0.1  7.0 

Blackberries 0.9  2.1  8.0 

Cranberries 0.5  0.7  8.0 

Peaches 0.5  0.2  9.0 

Muskmelons 0.7  0.3  10.0 

Raspberries 1.0  ?  10.0 

Whortleberries 0.7  3.0  10.0 

Apples 0.4  0.5  11.0 

Pears 0.4  0.6  11.0 

Apricots 1.1  ?  12.0 

Gooseberries 0.4  ..  12.0 

Mulberries 0.3  ..  12.0 

Pineapples 0.4  0.3  12.0 

Currants 0.4  .  .  13.0 

Oranges 0.9  0.6  13.0 

Mangoes .  .  13.0 

Grapes 1.0  1.0  15.0 

Nectarines 0.6  ?  15.0 

Cherries O.,s  0.8  17.0 

Figs 1.5  ..  17.0 

Huckleberries 0.6  0.6  17.0 

Plums 1.0  17.0 

Pomegranates 1.5  1.6  17.0 

Prunes 0.8  ?  19.0 

Bananas 1.5  0.7  20.0 

Persimmons 0.8  0.7  32.0 

Dates 1.9  Trace  54 . 0 

'Professor  Street  writes   (November   27,   1916),   "In  our  last  examination  of  27 
brands  we  found  the  reducing  sugars  to  range  from  0.27  to  1.52  per  cent." 


510  FOODS  AXD   THEIR  COMPOSITION' 

TAHLE  '223. — (Continued). 

Carbo- 

I'rotein,             F:it.  hydrate. 

ORANGES.1                 percent,           percent.  percent. 

Florida,  average  of  seven  analyses  (soluble  portion) S.O 

California,  average  of  eight  analyses  (soluble  portion)          8.3 

GRAPEFRUIT.' 

Porto  Rico,  average  of  two  analyses  (soluble  portion)          S.2 

California,  average  of  four  analyses  (soluble  portion) 0.9 

Florida,  average  of  four  analyses  (soluble  portion) 0.0 

DHIKD   FHCITS  CONTAIN  03   PKK  CKNT.   OH   Momo  OK  CAKHOHYDHATK. 

CANNKD   Fiurrs. 

Peaches 0.7                0.1  11.0 

Blueberries 0.0                 0.0  13.0 

PinoappU-.s (range  0.0  25.0)        0.4                 0.7  15.0 

Apricots ().'.)                    ?  17.0 

Pears 0.3                 0.3  1S.O 

Cherries 1.1                 0.1  21.0 

Crab  apples 0.3                 2.4  54.0 

Blackberries O.S                 2.1  50.0 

Jams,  jellies,  preserves  and  marmalade  contain  47  per  cent,  or  more  carbohydrate. 

XoN-AU'OHOLir    BlOVKHAGIOS. 

Tea  (0.5  oz.  to  1  pt.  water) 0.0 

Coffee3  (1  oz.  to  1  pt.  water) 0.7 

Cocoa1  (0.5  oz.  to  1  pt.  water)          1.1 

Cider (range  0-13.5)  4.5 

Cocoa  (0.5  oz.  to  1  pt.  milk) 0.0 

Cream  or  lemon  soda 7.0 

Sarsaparilla 7.0 

Birch  beer S.O 

(linger  ale S.O 

Root  beer ...  0.0 

MISCELLANEOUS. 

Plain  chocolate 25.0 

Cocoa  nibs,  roasted 2S.O 

Baking  powder (range  0-51 .5)  32.0 

Cocoa.          3s.  0 

Milk  chocolate 51  .0 

Milk  cocoa 52.0 

Custard  powders 5H.O 

Sweet  chocolate 07.0 

Duv   WINKS. 

California,  red,  Bordeaux  or  Claret 

"     Murgundy    

Zinfandel 

\\hite,  Rhine 

Burgundy       

"       Sautcrne          

1  drains  reducing  sugars  per  100  c.c. 

'-'  I'Voni  analyses  made  for  me  by  Kdward  II.  Frankcl.  New  Haven,  Conn. 

3  For  analyses  of  so-called   "hygienic  coffee"   consult    Report   of  Conn.   Agr.    Kxp. 
Sta.,    1'.I15,    Food    Products  and    Drugs,   p.  271.      In  one  preparation  widely  recom- 
mended as  a  substitute  for  coffee  molasses  is  an  ingredient. 

4  See  page  532. 


FOODS  AND   THEIR  CARBOHYDRATE  CONTENT 


si; 


TAULK  223. — (Continued). 


Carbo- 

DR\ 

WINES.  —  Continued. 

hydrate, 
per  cent.1 

French,  red     

(range 

0.11-  0.84) 

0  .  23 

"        white       .... 

(range 

0.65-  1.02) 

0.84 

German,  white     

(range 

0.09-   1.96) 

0  .  20 

Hungarian,  white        .... 

(range 

0.04-  0.86) 

0  .  25 

Italian,  red      

(range 

0.02-  2.70) 

0.16 

"        white        

(range 

0.02-  2.15) 

0.19 

North  Carolina     

(range 

0.08-  1.75) 

0  .  49 

Ohio     

(range 

0.07-  1.54) 

0.31 

Portuguese,  red    

(range 

0.01-  1.21) 

0.16 

white       .... 

(range 

0.10-  1.19) 

0  .  32 

Rhine,  red       

(range 

0.06-  0.27) 

0.13 

"       white  

(range 

0.02-  1.02) 

0.18 

Spanish,  red    

(range 

0.19-  0.54) 

0  .  35 

"         white      

(range 

0.27-  0.62) 

0.42 

Sparkling,  French  and  German 

.      .      .      .        (range 

0.13-  1.95) 

0.53 

Swiss,  red        

(range 

0.10-  0.27) 

0.13 

"      white    

(range 

0.08-  0.38) 

0.10 

Virginia      

(range 

0.06-  1.23) 

0.16 

SWEET  WINES. 

California  Port     

(range 

0.23-13.56) 

4.76 

"          Madeira  and  Sherry 

(range 

0.12-17.21) 

5.38 

French       

(range 

0.73-12.40) 

5.38 

German     

(range 

0.64-12.13) 

4.60 

Madeira     

(range 

2.48-  3.88) 

2.95 

Malaga      

(range 

12.50-25.20) 

18.32 

Marsala     

(range 

2.67-  8.24) 

3.25 

Port      

(range 

3.76-  8.17) 

6.04 

Rhine  

(range 

1.82-10.69) 

6  35 

Sherry        

(range 

0.52-  4.80) 

2.54 

Sparkling,  American 

(range 

6.51-12.02) 

8.28 

French  and  German 

(range 

8.00-18.50) 

10.92 

Tokav,  true     

(range 

1.86-20.50) 

12.62 

"        commercial    .... 

(range 

2.70-40.70) 

19.80 

Vermouth        

(range 

3.47-14.39) 

9.46 

OTHER 

ALCOHOLIC  BEVERAGES. 

Brand  v,  gin,  rum,  whisky    . 

0 

Absinth      

Trace 

Angostura        

4.2 

Beer     

4.5 

Weiss  bier        

4.6 

Ale        

5.1 

Porter  or  Stout    

7.0 

Malt  extract,  commercial     . 

10.6 

Curacao     

25.5 

Crcme  de  menthe      .... 

27.7 

Ki'immel    

31.2 

Benedictine     

32  .  6 

34  4 

Chartreuse      

34.4 

Maraschino     

52.3 

Malt  extract,  true      .... 

71.3 

1  Grams  reducing  sugars  per  100  c.c. 


olS  FOODS  AND   THEIR  COMPOSITION 

TAHLK  223. — (Continued). 

Alcohol 

by  Carbo- 

_  ,  volume,             hydrate, 

MANUFACTURER  <>K  AGENT  AND  BRAND.  percent.         percent.1 

Alfonso  it  Hipolito: 

Sancho  Vinos  do  Jerez  Amontillado   Don   Quixote   (Wm. 

J.  Sheehan  Co.,  New  Haven,  Agents) 20.00               1.23 

Brotherhood  Wine  Co.,  New  York  City: 

Sunnyside  Claret 11. S7             0.10 

Riesling 12.37              0.34 

Yin-Crest  Brut 12.24               1.00 

California  Wine  Association,  New  York  City: 

Riesling 11.31 

/infandel 11.02 

C'alwa  Distributing  Co.,  New  York  City:2 

"Calwa"  Brand  Greystone  (Light  Hock  Type)5     .      .      .  11. SI             0.19 

"Calwa"  Brand  La  Loma  (Burgundy  Type)2    ....  11.27             0.14 

"Calwa"  Brand  Vine  Cliff  (Riesling)2 10.90             0.17 

"Calwa"  Brand  Winehaven  (Table  Claret)2      ....  11.40             0.14 

II.  T.  Dewey  &  Sons  Co.,  New  York  City: 

I ves  Claret ...  12.53              0.24 

Moselle  Type S.37              0.14 

Old  Burgundy  Type 11.14              0.27 

Ruby  Claret 13.03              0.27 

Pedro  Domecq's  Manzanilla  Sherry3 20. so             0.32 

Kmpire  State  Wine  Co.,  Penn  Yan,  N.  Y.: 

DryCatawba 12. SO              0.15 

State  Seal  Champagne 12.39               1.51 

Los  Angeles  Co.,  Boston,  Mass: 

California  Chasselas 12.12              2.97 

California  Chasselas 11. OS              2.99 

California  Cutedel 11. S7              0.79 

California  Cutedel 11.50              0.19 

Monticello  Wine  Co.,  Charlottesville,  Va.: 

Extra  V.  Claret 12.  SO              0.25 

Norton's  Virginia 12.57             0.37 

Virginia  Claret 12.54              0.20 

Virginia  Hock 12.00              0.22 

A.  Pierlot  it  Co.,  Bouzy,  iiheims: 

Champagne  Vin  Nature  sans  Sucre 11.97             0.30 

Pleasant  Valley  Wine  Co.,  Rheims,  N.  Y".: 

Claret 11.22              0.29 

DryCatawba 12.02              O.ls 

Groat  Western  Kxtra  Dry                12.33              4.30 

M.  Schreiber,  Baden,  Austria: 

Diatotischer  Rothwoin  (K.  Loeb  it  Co..  New  York,  Agents)  11.21               0.  15 

Diiitetisoher  Weisswein  (K.  Loeb  it  Co.,  New  York,  Agents)  10. 4S              0.  1  I 

William  J.  Sheehan  Co.,  New  Haven,  Agents: 

California  Cabernet 11.49              0.31 

California  Hock 11.21               0.14 

California  Rie^ing 11  .15              0.14 

California  /infandel 11.32              0.10 

frbana  Wine  Co.,  I'rbana,  N.  Y.: 

Gold  Seal  Brut 12.14              2.30 

Gold  Seal  Absolutely  Dry 12.05              0.54 

Gold  Sparkling  Rod,  Special  Dry 11.20             2. SO 

Gold  Sparkling  Red,  Absolutely  Dry 1 1  .  9S              0.29 

Wilholmi,  Hock  it  Co.,  Frankfurt,  Germany: 

1910  Brauncbergor 11.10 

1  Grains  reducing  sugars  per  100  c.c. 

2  Sold  by  M.  /under  it  Sons,  New  Haven,  Conn. 

3  Sold  bv  Chris.  Nander,  Washington,  1).  C. 


COMPOSITION  OF  SO-CALLED   DIABETIC  FOODS 


519 


D.     COMPOSITION  OF  SO-CALLED  DIABETIC  FOODS. 

The  composition  of  so-called  diabetic  foods  has  been  more 
thoroughly  studied  at  the  Agricultural  Experiment  Station  in  Xe\v 
Haven  than  elsewhere. 

In  using  the  tables  of  the  Connecticut  Agricultural  Experiment 
Station  it  should  be  understood  that  the  percentages  in  the  protein 
column  are  uniformly  calculated  from  the  nitrogen  found,  using 
the  conventional  factor  (5.25.  \\ith  pure  wheat  products  the  factor 
5.7  gives  more  accurate  results,  and  strictly  speaking,  the  latter 
factor  should  be  used  for  gluten  flours  and  other  gluten  products. 
In  baked  products  where  the  protein  may  be  derived  from  other 
sources  than  wheat,  such  as  soya  beans,  cotton  seed,  nuts,  etc., 
it  is  impracticable  to  vary  the  factor  with  each  particular  food 
without  causing  endless  confusion.  Similarly,  it  has  seemed  to  the 
analysts  best  to  retain  for  the  flours  the  old  factor  for  the  sake 
of  uniformity.  In  the  high-grade  ground  glutens,  containing  as 
much  as  13.7  per  cent,  of  nitrogen,  the  use  of  the  proper  factor 
would  reduce  the  protein  by  about  7.5  per  cent,  and  the  nitrogen- 
free  extract  would  be  increased  in  the  same  proportion. 

The  terms  "nitrogen-free  extract"  and  "carbohydrates"  are  used 
synonymously,  but  the  explanation  of  nitrogen-free  extract  in  the 
preceding  paragraph  should  be  borne  in  mind.  The  values  given 
for  starch,  however,  are  absolute,  being  direct  determinations  and 
having  no  connection  with  the  protein  factor  used.  A  "0"  means 
no  starch  was  found,  but  a  blank  space  does  not  mean  the  same, 
indicating  merely  that  starch  was  not  tested  for. 

TABLE  224. — ANALYSES  OF  SO-CALLED  DIABETIC  FOODS. 

(For  original  analyses  sec  Connecticut  Agricultural  Experiment  Station,  Report 
for  1913,  Part  1;    Report  for  1914,  Part  5;    Report  for  1915,  Part  5.) 


Date 

of 
analysis. 


Manufacturer  and  Brand. 


1910 
1912 

FLOURS  AN»  MEALS. 
Acme  Mills  Co.,  Portland,  Ore.    . 
Amthor  &  Co.,  Halle:  Weizen-Protein 
Herman  Barker,  Somerville,  Mas.s: 

9 
84 

4  ] 
1 

1 
1 

9 
4 

77 
4 

4 

8 

71 

4 

Barker' 

s  Gluten  Food, 

"A"     . 

SO 

9 

0 

5 

3 

7      trace 

1913 

Barker' 

s  Gluten  Food, 

"B"     . 

NO 

1   1 

0 

6 

7 

2 

3 

7 

1913                  Barker' 

s  Gluten  Food, 

"C"     . 

84 

1 

0 

G 

8 

6 

3 

4 

1914     'Battle  Creek 

Sanitarium  Co 

,  Battle 

Creek,   Mich.,  80  per  cent 

Gluten 

Meal     .       . 

S4 

o  i 

5 

8 

1907      Bischof  &  Co 

,  London:  Gluten  Four 

79 

8 

3 

6 

5 

0 

3(34 
3  Gs 

370 
375 
377 


372 


FOODS  AND   THEIR  COMPOSITION 
TABU-:  224. — (Continued). 


Date                                                                                                     .j 
of                        Manufacturer  and  Brand. 

analysis.                                                                                               a  c, 

'Ss 

2C 

C-, 

<u 

•       2  •          ^ 

"c         "?  '£             "a 

C-                 S*i  O                       w 

O                   «     w                        •    L 

t-      '      °  t.           o  t" 

•y  c.        i;  S,        cs  c, 

a              B         '     +, 

fa          O       i    cc 

Caloulatod 
calorics  per 
100  grams. 

FI.OTKS  AND  MKALS.  —  Continued. 

1000       Callard,  Stewart  &  Watt,  London: 

(  'asoid  Flour       S2., 

'>        1.0        3.1          0 

357 

1913       Ceroo  Co.,  Tappan,  N.  V.: 

Soy  Bean  Gruel  Flour  .      .      .      13. 

1      21.4      24.9      trace 

405 

1013       Farwell  tt  Rhinos,  Watertown,  N.  Y. 

(.lluton  Flour       43. 

1.2      40.0      3S.1 

370 

1013                  Gluten  Flour       40  ; 

i         1.1      42  .  9      32  .  S 

307 

1013                   Cresco  Flour        IS. 

1.0      07.4      57.2 

351 

1013                   Special  Dietetic  Food    .       .       .       27.  t 

>        2.S     50.  0      40.0 

302 

1010      Gericke,  Potsdam:  Aleuronat       .      .      S3.- 

I        3  .  3        3.1 

370 

1013      ('.olden   Rod   Milling   Co.,   Portland, 

Ore.,  Acme  Special  Flour     .      .      .      15.  > 

•;        1.4      71.4      57.9 

301 

1013       O.  I?.  Oilman,  Boston,  Mass.: 

Gluten  Flour       47.; 

2.0      40.4      31.4 

369 

1000       Karl  Goldscheidcr,  Carlsbad: 

Conalbin-Mehl,  No.  1    .              .       10  ! 

0.4      7S.  S 

302 

1010       Gumport,  Merlin:    I'ltramohl         .       .       30..  r 

>      44.0        9.4 

585 

100S      Hazard's  Wheat  Protein    ....      41.  i 

>         1.2      49.1 

374 

1013      Health  Food  Co.,  New  York: 

Almond  Meal      50.; 

14.  S      17.9      trace 

400 

1014                   Almond  Meal      40.1 

21.S      15.0          0 

457 

1911                  G    15   X    Cold    Blast    Flour,  25 

I>o  r  cent,  protein         .       .       .       10. 

0  .  0      70  .  0      OS  .  9 

307 

1913                   Proniren     (Gridle-eake    Flour)      37..' 

1.2        .  .        37  .  7 

349 

1013                   Glutosac  Gluten  Flour         .       .       30.  '. 

)        2.3      47.5      30.9 

370 

1014                  Gluten  Flour  No.  1        ...      75.1 

0.9      12.S        7.1 

362 

1013                    Protosar  Gluten  Flour         .       .       42.1 

'  \     1.7     46.4     30.3 

372 

1913                   Protosoy  Soy  Flour        .       .       .       42..' 

,       19.S      24.5      trace 

440 

1913                   Pure  Washed  Gluten  Flour       .       SO.; 

1.0      20.5        7.0 

3SO 

1014                   Gluten  Flour       15.! 

»        2.0      42.3      31.5 

370 

1014                   Protosoy  Soy  Flour        .       .       .       42.! 

10.2      20.0         1.9 

448 

1014                   Pure  Washed  Gluten     .       .       .       S5  .  ( 

>         1.0        5.4        2.S 

373 

1S92-0  H.  Ilundhausen,  Hamm.: 

Aleuronat  (pure)       ....       SO.' 

0.5        4.0 

305 

1000      .Hreh  Diabetic  Food  Co.,  Xew  York: 

1000                   Diabetic  Flour    14.: 

2.2      71.9      00.  O1 

305 

1000                   Diabetic  Flour    12.1 

1  .  S      72  .  7 

355 

1013                   Flour         l   14.  -1 

2.3      72.0      00.9 

370 

1013                    Patent   Barley      11  . 

1.0      SO.  2      07.  S 

3S1 

1013                   Patent  Cotton  Seed  Flour         .       40.- 

12.7      21.3        0.0 

396 

1013                   Patent  Lentils  Flour      .       .       .       27.: 

1.2      50.  S      42.0 

350 

1013                   Protein  Flour      31  .• 

2.0      50.7       IS.  5 

370 

1913                   Soja  Bean  Flour        ....       42.: 

IS.  2      25.  S        0.0 

135 

1913                   Wheat  and  Barley  Flour     .       .       11  .  > 

1.9      73.5      00.  22 

358 

1011        .Johnson  Kducator  Food  Co.,  Boston, 

Mass.: 

1       1           Ml     •)           1(1     <l 

•(7.1 

1  Determined   1  >y  the  diastase  method,   without    previous  washing  with   water,  ant 
calculated  as  starch. 

-  Possibly  in  part  due  to  the  copper-reducing  power  of  the  agar-agar  present. 


COMPOSITION  OF  SO-CALLED  DIABETIC  FOODS         521 
TAHLK  224. — (Continued). 


Date 

of 
analysis. 

0 

Manufacturer  and  Brand. 

Go                   0             A 
'o  t-                   t-              £ 
-So             -  o          •£ 
o  &        •£  ft         i 

£     &    \t 

[.         y 

«  -*-»                  -^>       '     **3        ~ 
3  C                   fi             O  SR  83 

?£        ,8    :   £•£& 
>  u       iU      "5^0 

2  0               £   0               0    -  O 

;  ft         a  a        -3  -~ 
x           O 

FLOURS  AND  MEALS.  —  Continued. 

1912 

The  Kellogg  Food  Co.,  Battle  Creek, 

Mich.: 

20  per  cent.  Gluten  Meal   .      .      27.5        0.5      7 

1.7      49.6        357 

1913 

40  per  cent.  Gluten  Flour  .      .      43  .  7        0.9      4' 

7.3      40  .  5        367 

1912 

80  per  cent.  Gluten        .      .       .      81.3        0.9 

6  .  2        365 

1913 

Kugene  Loeb,  New  York: 

Gluten  Cracker  Meal    .      .      .      27  .  8        7.7      5. 

1.5     40.2        394 

1913 

Imported  Gluten  Flour       .      .      76.3        0.9      1 

1.8        4.4        361 

1913 

Pure  Gluten  Flour  .      .       .      .      40  .  3        2.4      4( 

5  .  3      39  .  6        368 

1913 

Whole  Wheat  Flour       .      .      .      14.6       2.2     7( 

).5      54.6        360 

1913 

Gluten  Flour       43  .  9        1.1      4< 

1.4      39.8        363 

1915 

Lister  Bros.,  New  York: 

Diabetic  Flour    84  5        36 

0           372 

1913 

Thos.  Martindale  &  Co.,  Phila.: 

Special  Gluten  Flour     .      .       .      40.3        1.5      4< 

).l      41.4        371 

1913 

Mayflower  Mills.  Fort  Wayne,  Incl.: 

Bond's  Diabetic  Flour         .      .      40.2        1.3      4S 

•1.3      40  .  6        366 

1913 

Theo.  Metcalf  Co.,  Boston,  Mass.: 

Soja  Bean  Meal,   18  per  cent. 

starch  41.0      20.0      2. 

5.0        ..          444 

1913 

Vegetable  Gluten,  8.1  per  cent. 

starch  80.4        1.5        ' 

)  .  8        5.9        374 

1901-2 

H.  Niemoller,  Giitersloh:    Roborat    .      82.3        3.7        '. 

2.9        .  .          374 

1913 

Pieser  Livingston  Co.,  Chicago: 

Gluten  Flour      433        1  .  3     4( 

5.2      38.4        370 

1911 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Flour  .      .      .      .      38.3        1.6      5( 

).8     42.4        371 

1900 

Gum  Gluten  Ground     .      .      .      50  .  1        1.9      3< 

).6      38.  61       376 

190G 

Hoyt's  Gum  Gluten       .       .       .      31.8        1.6 

52.  O1       358 

1901 

Plain  Gluten  Flour         .      .      .      53  .  6        1.2      3- 

L  5         .  .           363 

1914 

Hoyt's    Gum    Gluten    Biscuit 

Crisps     52.7        0.5      3f 

>.0  I  31.2        368 

1914 

Breakfast  Food     .      .       .      .      45.4        0.9      4( 

>.4      39.2        375 

1914 

Flour,  50  per  cent.     .      .      .      49.7        1.2      4] 

.5      37.1        375 

1914 

Flour,  Ground      ....      41.9        0.9      41- 

<  .  1      42  .  6        369 

1914 

Granules    42.7        0.7      4^ 

i.8     41.9        372 

1914 

Noodles      40.5        1.2      4? 

).l      41.8        369 

1914 

Self-raising  Flour        .      .      .      42  .  7        0.8     4c 

>  .  0      39  .  0        357 

1914 

Special  Flour         .      .      .      .      90  .  7        0.7        1 

.7        2.2        376 

1914 

No.  1  Dainty  Fluffs  .      .      .      79.9        0.5      1] 

.3      10.7        370 

1914 

No.  2  Dainty  Fluffs  .      .      .      66.3        0.5      2^ 

t.9      21.9        369 

1913 

Rademann's  Nahrmittelfabrik, 

Frankfurt:    Diabetiker  Mehl     .      .      37.9        0.8      5( 

).7      46.8        362 

1913 

Sprague,  Warner  &  Co.,  Chicago: 

Richelieu  Gluten  Flour       .      .      47.7        1.2      3< 

.7      31.6        368 

1913 

G.  Van  Abbott  &  Sons,  London: 

Almond  Flour     24  .  6      58  .  6        ', 

.9        0.0        657 

1913 

Gluten  Flour       75.1        0.9      11 

.6      12.4        359 

1  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


D:it« 

of 

analvs 


FOODS  AND   THEIR  COMPOSITION 

TAHLK  224.— (Continued). 


Manufacturer  and  ]5r;ui<l. 


20 .  S 
17.4 


2.1 
2.0 


I1" i.orus  AND  MEALS. — Continued. 
1018       Wilson  Bros.,  Rochester,  N.  Y. 

Ciluton  Flour.  ~  Standard  . 
1018  Self-raising,  i  Standard       .       . 

1018       Waukosha      Iloaltli      Products     Co., 

Waukesha,  Wise.:    Hepco  Flour 


PROTKIN  PREPARATIONS. 
1000-1    Kiweiss-Kxtrakt    Co.,    Altona,    Ger- 
many:   Soson 01.2  0.8 

1002     i  Kreoke  &  Co.,  Salzuflen:    Fiier^m     .  s8.S  4.5 

1013      Menley&  James,  New  York:  Clidine  01.4  O.s 

1000  Plasmon  Co.,  London:  Plasnion  .      .  7s. 7  2.7 
1015      Schulenburs    Oil    Mill,    Shulonburj>;, 

Texas:    Allison's  Cotton-seed  Flour  /JO  .  4  11.2 

1001  Troponwerke,  Mulheim:   Tropon      .  SS.5  0.8 


04.6 
63.5 


54 .  n 

51.S 


861 
842 


44S 


872 
8M 

877 
880 


1018 
1S02 
1S02 


1010 
1010 
1010 

1010 
1014 
1014 

1010 

1010 
1010 
1010 
1010 


1010 
1010 
1010 
1010 
1S02 


SOFT  BHKADS. 
Ferguson  Bakery,  Boston,  Mass.: 

Gluten  Bread      .... 
Frank  (V:  Co.,  Bockenheim: 

Protoin-HotfKonbrot       .       . 

Protein-Weizenbrot        .       . 
Fritz,  Vienna: 

Aleuronatbrot 

Kleborhr 

Litonhrot 
Froinni  &  Co.,  Dresden: 

Contrliitinhrot 

Litonhrot 

Con^lnt  in  Drop 

CoiiKlutin- 
Gorirkc,  Potsdam 

Doppcl-Por 

Dreifach-P 

Kinfach-Po 

Sifarhrot 
Karl  Goldscheider,  Carlsbad: 

Sinamylbrot 
Gumport,  Berlin: 

Diahetiker-Dopiiel-Schwarz 

Diabctiker-Doppel-Weissbr 

Diubetiker-Einfaoh-Sc-hwarz 

niabotikor-Kinfach-Weissbr 

ritrahrot 
F.  Giintlier,  Frankfurt  :    Klel)orbr 


2s.  2 


17.8 


2s8 
2S4 


(t    .     .     .     . 

15 

6 

0 

,8 

16 

.6 

250 

Schwarz 

.       21 

5 

IS 

.6 

8S 

6 

15 

.4 

jadcn: 

>t     .      .      .      . 

IS 

3 

47 

o 

85 

X 

14 

.8 

n  )J  »s 

50 

s 

1 

1 

86 

1       20.2 

85S 

wioba'-k 

14. 

8 

21 

3 

(i      20.7 

470 

erhrot   . 

20 

6 

85 

1 

rterbrot 

.       80. 

f 

6. 

5 

26 

()       10.S 

2S5 

lerbrot 

.       17 

S 

1 

S 

48 

2 

2SO 

87 

3 

5  . 

.3 

15 

0       12.8 

257 

1  Detcrmini'd  l>y  the  diastase  method,  wilhoul  previous  washiiifj;  with  wati 
calouliited  as  starch. 

-Chiefly  derived  from  Soja  bean  and  therefore  non-assimilalile  and  for  p 
can  be  considered  carbohydrate-free.-  F,.  P.  .1. 


COMPOSITION  OF  SO-CALLED  DIABETIC  FOODS          523 
TABLE  224.— (Continued). 


Date 
of 
analysis. 

Manufacturer  and  Brand. 

r  c, 
C 

5 

Carbohydrate, 

per  cent. 

~ 

C'alculated 
calories  per 
100  grams. 

1906 

SOFT  BREADS.  —  Continued. 
Health  Food  Co.,  New  York: 
Glutosac  Bread         .... 

27.4 

2  7 

36  .  1 

29.  9' 

278 

1914 

Glutosac  Bread         .... 

27.2 

2.1 

31.1 

22  2 

1906 

Health  Food  Co.: 

Protosac  Bread  

32  .  5 

37  .  0 

1.6  I 

292 

1914 

Protosac  Bread  

29.8 

1.8 

35  .  2 

27.7 

276 

1914 

.1.  Heinbockel  &  Co.,  Baltimore,  Md.: 

Diabetic  Bread  for  Diabetes    . 

8.6 

1.5 

52  .  1 

40.4 

256 

1892-6 

R.  Hundhausen,  Hamm.: 

Aleuronatbrot,  low  gluten 

17.3 

40.6 

0.3 

234 

1906 

Jireh  Diabetic  Food  Co.,  New  York: 

Whole  Wheat  Bread      .      .      . 

9.4 

48.6 

0.4 

236 

1913 

Eugene  Loeb,  New  York: 

P.  &  L.  Genuine  Gluten  Bread 

10.4 

2.6 

53  .  7 

44.2 

280 

1914 

P.  &  L.  Genuine  Glubetic  Bread 

38.8 

4.1 

25  .  7 

19.2 

294 

1915 

Lister  Bros.,  Andover,  Mass.: 

C^n^ciii  13  rend 

36  6 

18.4 

o 

322 

1910 

Rademann's  Nahrmittelfabrik  : 

Diabetiker-Grahambrot 

9.8 

5.1 

49.4 

45.6 

283 

1910 

Schwarzbrot 

14.5 

2.5 

15.5 

45.8 

283 

1910 

Diabetiker  Weissbrot    . 

2.3.3 

0.5 

40.1 

37  .  0 

258 

1910 

"D-K"  Brot  (dry)         .      . 

12.3 

5S  .  9 

1910 

Litoiibrot             ..... 

30  2 

2.5 

21  .0 

17.5 

230 

1910 

Seidl,  Munchen: 

\leuronatbrot     ..... 

21.9 

0.3 

47.3 

2<sO 

1910 

Klebcrbrot                 .... 

18.6 

0.7 

54.4 

298 

HARD  BREADS  AND  BAKERY 

PRODUCTS. 

1907 

Bishof  &  Co.,  London: 

Diabetic  Gluten  Bread 

73.1 

0.5 

14.3 

354 

1907 

Essential  Bread  for  Super-Ali- 

mentation         

26.6 

1.6 

59  .  6 

359 

1912 

Brusson  Jeune,  Yillemue,  France: 

Gluten  Bread 

37  3 

1  .8 

47.  1 

40.  1 

354 

1909 

Callard,  Stewart  &  Watt,  London: 

Almond  Biscuit,  plain  . 

28  .  3 

28.0 

36.8 

512 

1909 

Almond  Shortbreads 

19.5 

52.1 

27.0 

630 

1913 

Casoid  Biscuits,  No.  1 

66.8 

18.8 

5  .  <s 

4.0 

460 

1909 

Casoid  Biscuits,  No.  2 

57.8 

25.5 

5.6 

0  .  0 

4S3 

1909 

Casoid  Biscuits,  No.  3 

54.3 

25.0 

7.S 

trace 

473 

1909 

Casoid  Dinner  Rolls 

78.0 

11.1 

2.1 

420 

1909 

Casoid  Lunch  Biscuit    . 

25.5 

44  .  9 

21  .6 

593 

1909 

'37  0 

32  .  3 

20  .  s 

522 

1909 

Cocoanut  Biscuit  +Saccharin   . 

16.6 

61.3 

16.4 

1909 

Ginger  Biscuit  -(-Saccharin 

17.1 

58  .  6 

is.l 

668 

1913 

Kalari  Batons     

43  .  2 

39  .  0 

7.4 

0 

553 

1909 

Kalari  Biscuits          .... 

56  .  9 

31  .4 

1  .7 

517 

1909 

Prolactic  Biscuit       .... 

42.9 

27.5 

19.3 

496 

1  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


524 


FOODS  AND   THEIR  COMPOSITION 
TABLE  224.— (Continued). 


Date 
of 

analysis. 

Manufacturer  and  Brand. 

c 

+J 

«           ~        2 
c            c        "5 

B  §                   t            £ 

'St.           i.        2 
£            fa             O 

£ 

IM 

0 

^  c 
^  t, 

X 

Calculated 
calories  per 
100  grams. 

HARD  BUEADS,  ETC.  —  Continued. 

1913 

Charrasse     Biscuits    Croquettes     au 

Gluten        r 

4.3        5.4      52 

.3 

30  .  0 

395 

1913 

Biscottes  Lucullus    .... 

1.4        5.7      73 

.4 

59  .  2 

391 

1913 

Gluten    Exqui.s    Biscuits    aux 

Ainandes    ' 

8.1      23.8      15 

.0 

25  .  5 

489 

1913 

Gluten  Fleur  de  Neige  Pain     .      : 

5.9      12.5      42 

.8 

25  .  1 

427 

1913 

Mignonettes  au  Gluten 

0.1        5.7      43 

.0 

27  .  3 

386 

1913 

Pain  de  Gluten  

0.8  i     5.3      43 

.5 

27.2 

385 

1913 

Tranches  Grillees  pour  Potage      -1 

0.6        3.0      45 

5 

28.8 

377 

1892 

Frank  &  Co.,  Bockenheim: 

Erdnuss-Kakes  

2.2      19.1      30 

5 

447 

1910 

Fritz,  Vienna: 

Braunes  Luftbrot  "B"        .      .      4 

2.6        .  .         19 

8 

1910 

Mandelbrot  1 

5.4        ..        23 

1 

1913 

Fromm  &  Co.,  Dresden: 

Almond-form       Wafers       with 

Chocolate         

4.8      29.0      02 

3 

14.0 

529 

1913 

Butterbrezeln     i 

2.3      1G.5      02 

7 

43  .  1 

449 

1913 

Crackers         '. 

2.9        7.7      08 

4 

58  .  2 

395 

1913 

Eierbiscuit     ! 

8.8      11.4      00 

.6 

37.5 

420 

1910 

Eiweissbrot   

5.5         .  .      i  37 

.5 

1913 

Hazelnuss-Stangen  ....'. 

3.4      10.0      00 

.8 

0.0 

441 

1913 

Luft  Bread    .r 

0.9        1.0      30 

.7 

23  .  4 

335 

1913 

Makronen      

4.1       19.4      50 

2 

0.0 

456 

1913 

Salz-Stangen       1 

3.0      15.6  !  01 

2 

39  .  1 

437 

1913 

Stangenin      '. 

4.0  ,  13.0      04 

.4 

51.6 

431 

1913 

Uni  Bread      7 

1.7        1.7        9 

.4 

2.9 

340 

1910 

Gericke,  Potsdam  : 

1910 

Doppel-Porterzwieback      .      .      " 

9.1         .  .      i  41 

.0 

Mandelbrot                                          1 

0.2        .  .         43 

.3 

1910 

Porterbiskuits     ; 

6  .  1   !      .  .         03 

.0 

1910 

Porterzwieback  - 

0.4         .  .         72 

.0 

1910 

Sifarbiskuits        1 

0.2         ..        35 

.3 

1914 

Karl  Goldscheider,  Carlsbad: 

Cocosnuss-Biskuits     fiir     Dia- 

betiker        j  C 

4.4      45.4      13 

.9 

0.0 

1914 

Vanilla-Biskuits  fiir  Diabetiker 

0.4      30.3      10 

.8 

0.0 

1914 

Honigkuchen  fiir  Diabetiker    . 

0.3      38.8      13 

.9 

0.0 

1914 

Aleuronat-Conglutin  Cakes      .      l 

'0.0      15.11      51 

.3 

31  .7 

452 

1914 

Butter-Brezeln    

0.5       14.9      (17 

.0 

43  .  9 

446 

1914 

Saccharin-Oblaten  ohne  Zucker 

0.5      22.  (i      51 

.1 

33  .  5 

474 

1914 

Tee-Geback              .... 

7.0      27.3      00 

.8 

18.0 

517 

1914 

Zwieback        '. 

J1.3        3.0      05 

.3 

51  .7 

379 

1910 

Groetzsch,  Frankfurt: 

Diabetiker-Salzbrezeln 

!4  .  5      35  .  4      22 

.9 

548 

1910 

Pfefferiiiisse 

(<t  2      32  0       10 

.3 

486 

1910 

(  lumpert,  Berlin: 

Uiabetikcr-Stangen                         '. 

il.l      49.5      11 

.0 

014 

1910 

Doppel-Diabetiker-Zwieback  . 

!2  .5      32  .  1      27 

.0 

27.1 

529 

COMPOSITION  OF  SO-CALLED  DIABETIC  FOODS 


TABLE  224. — -(Continued). 


Date 

of 
analysis. 

Manufacturer  and  Brand. 

C   5 

S\ 

£< 

2  • 

o     ,      >>  Z 

3                      0        !       J3    0                 „- 

1   i   I*      cT      1 

I 

Calculated 
calorics  per 
100  grains. 

HARD  BREADS,  ETC.  —  Continued. 

1913 

Health  Food  Co.,  New  York: 

Alpha  Best  Diabetic  Wafer      .      66  . 

1      13.6      11.3      trace 

432 

1914 

Alpha  Best  Diabetic  Wafer      .       67  . 

1        8.4      11.7        1 

.3 

391 

1913 

Diabetic  Biscuit       .      .      .      .       25  . 

0        9.2      54.2     46 

.5  , 

400 

1914 

Diabetic  Biscuit       .      .      .      .      35  . 

9        8.8     46.5      39 

.8 

409 

1913 

Gluten  Nuggets        .      .      .      .      30  . 

2      12.8     48.3      38 

.6    ! 

429 

1906 

Glutona    22. 

1      11.8     58.5      54 

.9' 

429 

1906 

Glutosac  Butter  Wafers      .      .      27  . 

6      12.9      49.4     41 

.2'! 

424 

1906 

Glutosac  Rusks         .      .      .      .       36  . 

5        3.8      51.6     42 

.o1 

387 

1906 

Wafers,  Plain      29 

4        9.6     49.9     41 

.  61 

404 

1906 

Zwieback       32. 

5        6.9     49.3      40 

.91 

389 

1913 

No.  1  Proto  Puffs    .      .      .      .       76  . 

3        2.9      10.7        4 

.3 

374 

1913 

No.  2  Proto  Puffs    .      .      .      .       56. 

6  i     2.1      30.7      19 

.0 

368 

1906 

Protosac  Rusks         .      .      .      .       40  . 

9        2.0      48.7      43 

.91 

376 

1913 

Protosoy  Diabetic  Wafers        .      43  . 

1      24.9     21.2        4 

.7 

481 

1906 

Salvia  Sticks                                       39 

2      20.8        2.4      18 

.  71 

440 

1914 

Gluten  Nuggets                                31 

7      14.3     45.7     34 

.9 

438 

1914 

Gluten  Butter  Wafers  .      .      .      31  . 

1      13.9     47.0      38 

.9 

438 

1914 

Gluten  Rusks           .      .      .      .      39. 

3        3.4     47.0      33 

.6 

376 

1914 

Gluten  Wafers,  Plain    .      .      .       42  . 

6        1.7      44.3      29 

.6  ' 

363 

Gluten  Zwieback      .       .             .       36  . 

4        7.7      46.6      32 

.5 

401 

1914 

Manana  Gluten  Breakfast  Food     42  . 

6        2.0      43.6      29 

.9 

363 

1914 

No.  1  Proto  Puffs    .      .      .      .       72.3        2.8      13.0        9 

.2 

366 

1914 

No.  2  Proto  Puffs    .       .      .      .       58  . 

8        2.1      27  .  0      20 

.7 

362 

1914 

Protosac  Rusks                                  39 

7        3.0      46.7      35 

.9 

373 

1914 

Protosoy  Diabetic  Wafers         .       37  . 

1      23.5      29.3      14 

4 

477 

1914 

Salvia  Almond  Sticks    .      .      .       22.3      29.9      41.0      28 

3 

523 

1913 

Heinz  Food  Co.,  Chicago: 

Gluten  Biscuits         .      .      .      .       12.8      18.3      57.7      21 

4 

447 

1914 

Heudebert,  Paris: 

Pain  d'Aleurone  pour  Diabet- 

iques     76  . 

1        1.5        9.2        4 

2 

354 

1914 

Pain  do  Gluten   pour   Diabet- 

iques     80. 

7        0.8        6.5        3 

4 

356 

1914 

Pain  de"  Essential  "en  Biscottes    26.4       1.2     62.2     49 

9 

365 

1892-6 

R.  Hundhauscn,  Hamm.: 

Aleuronatzwieback,  high  gluten      66. 

2        5.0      17.7 

381 

1892-6 

Aleuronatzwieback,  low  gluten      22. 

9        8.6      59.6 

407 

1894 

Aleuronat-Biskuits   .      .      .      .      24  . 

8      11.2      52.2 

409 

1891 

Aleuronat-Kakes       .      .      .       .       20  . 

1        9.4      64.8 

424 

1913 

\leuronat-Kakes                                 54 

5      27.4         .  .        tra 

no 

492 

1913 

Huntley  &  Palmer's  Akoll  Biscuits    .       54. 

5      27.4        6.8      trace 

492 

1906 

Jireh  Diabetic  Food  Co.,  New  York: 

Diabetic  Biscuits       .      .      .       .       14. 

8        3.7      72.3      65 

.41 

382 

1906 

Diabetic  Rusks    14  . 

6        5.0      67.7 

374 

1913 

Dietetic  Biscuits        .      .      .      .       13  . 

2        7.4      70.  S     49 

6 

403 

1913 

Dietetic  Rusks     14  . 

9        8.7      68.0      47 

0 

410 

1906 

Wheat  Nuts          19.0      15.0      54.5      50 

I1 

434 

1  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 


FOODS  AND   THEIR  COMPOSITION 
TAHI,K  224. — (Continued). 


„  C.  ~ 


.Manufacturer  and  Brand. 


II.VHl)    BUKADS,    ETC.  Coilt  ilHUMl. 

1  !)()(> 

Johnson  Educator  Food  Co.,  Boston: 

Almond  Biscuits        .... 

20 

o 

s 

8 

54  .  3 

50  .  01 

412 

L906 

Diabetic  Biscuits       .... 

25 

3 

7 

5 

59.0 

54.0' 

405 

UK  Hi 

Educator      Crackers,      Greseni 

Gluten              

23 

0 

4 

G 

63  .  1 

57  .  91 

386 

1013 

Educator  Gluten  Bread  Sticks 

35 

9 

7 

2 

45.  S 

37  .  5 

302 

1911 

Gluten  Cookies    

26 

4 

16 

0 

49  .  S 

37  .  S 

440 

i  DOC. 

Gluten  Rusk,  Gresoni  Gluten    . 

•»•) 

1 

0 

3 

68  .  1 

63.3' 

364 

1  1)0(1 

Gluten  Wafers      

30 

3 

0 

4 

61  .2 

57.0' 

370 

1906 

Glutinp,  Greseni  Gluten 

21 

9 

0 

b 

07.  7 

63.  11 

366 

1012 

The  KelloKK  Food  Co.,  Battle  Creek, 

Mich.: 

A  vena-Gluten  Biscuit     . 

21 

4 

12 

7 

55  .  5 

41.1 

422 

1913 

Potato  Gluten  Biscuit    . 

41 

5 

0 

5 

48.0 

30  .  5 

363 

1000 

Pure  Gluten  Biscuit 

4S 

3 

3 

3 

39  .  1 

370 

1013 

Taro-Gluten  Biscuit 

31 

3 

0 

5 

57  .  7 

4,S  .  2 

361 

101:5 

40  per  cent.  Gluten  Biscuit 

37 

2 

0 

8 

53  .  2 

45.0 

369 

1012 

SO  per  cent.  Gluten  Biscuit 

82 

4 

0 

9 

4.4 

4.7 

355 

1.S05 

Kirche,  Diisseldorf:    Alcuronat-Kakes 

17 

0 

13 

7 

61.8 

430 

1010 

Klopfer  Chernische  Fahrik,  Dresden: 

Glidinchrot     

47 

G 

'> 

9 

34  .  0 

32  .  S 

350 

1013 

Eugene  Loch,  New  York: 

Gluten  Luff,  Bread    .... 

27 

9 

9 

2 

54  .  2 

44.1 

111 

101  1 

Gluten  Luft  Bread    .... 

52 

4 

13 

2 

26.0 

22  .  0 

433 

914 

Chocolate  Almond  liars 

If) 

3 

41 

0 

31.8 

.)  .  7 

561 

914 

Diabetic,  Almond  Macaroons     . 

46 

5 

37 

7 

s  .  o 

0.6 

558 

9  1  4 

Diabetic  Dread  Sticks 

50 

4 

3 

4 

34  5 

24   (i 

371 

914 

Diabetic  Chocolates 

II 

0 

")1 

4 

23  .  0 

6.9 

614 

914 

Diabetic  Lady  Finders 

56 

6 

2S 

3 

(i.O 

I  .s 

505 

914 

Diabetic  Sponge  Cookies 

54 

7 

30 

1 

5.0 

1  .2 

510 

oi.v, 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Biscuit  Crisps 

12 

9 

0 

7 

4s.  5 

30.3 

372 

1913 

Rademai  m's  Nuhrmittelfabrik, 

Frankfurt: 

Diabetiker  Biskuits         .      .      . 

20 

G 

10 

G 

44  .  5 

25  .  9 

473 

1913 

Hret/el       

31 

4 

S 

5 

50.1 

•10.7 

102 

1913 

Cakes         

20 

G 

13 

5 

47  .  2 

30.  1 

120 

lso3 

I  )iabctiker-(  'hokoladc-Hiskuits 

11 

9 

27 

0 

21.9 

11.8 

516 

Hademann's  XiUirmit  telfabrik, 

Frankfurt  ((  'ontinued)  : 

ioi"3 

Diabetiker  Dessert-Gel  >:ick 

22 

2 

12 

4 

27  .  5 

5.  0 

580 

1913 

I  )iabetiker  Makronen 

23 

2 

Is 

() 

20.li 

3.0 

607 

1913 

Diabetiker  Staiificn   .... 

17 

1 

11 

.2 

20.5 

21  .1 

586 

1010 

Diabetikcr-Zwieback 

2.) 

.2 

11 

.9 

5  1  .  3 

17.0 

113 

IS93 

Krdmiss-Biskuits       .... 

31 

.  N 

21 

.5 

30.  1 

9.0 

ISO 

1913 

Kiisestantien   

17 

.  5 

33 

7 

46.4 

38.0 

521 

S07 

Schelle,  !  Braunschweig: 

.  \Ieuronat-Kakes        .... 

10 

9 

10 

S 

63  .  1 

120 

nit   previous  washing  with  water,  and 


COMPOSITION  OF  SO-CALLED  DIABETIC  FOODS 
TABLE  224:— (Continued). 


Date 

of 
analysis. 

Manufacturer  and  Brand. 

Protein, 

G 

rt 

Calculated 
calories  per 
100  grams. 

per  cent 

I 

a 

Carbohydi 

per  cent 

a 

G 

HARD  BREADS,  ETC.  —  -Continued. 

1910 

Seidl,  Munchen:    Kleberzwieback 

14 

.8 

7 

.8 

66 

.6 

396 

1913 

Roman     Fill,     Karlsbad:     Carlsbad- 

Water  Biscuits,  "Sprudel"  Brand  . 

10 

.0 

5 

2 

74 

.8 

55 

.6 

386 

1913 

G.  Van  Abbott  &  Sons,  London: 

Caraway  Biscuits  for  Diabetics 

35 

.6 

37 

.  5 

15 

.9 

8 

.6 

544 

1913 

Diabetic  Rusks  for  Diabetics    . 

70 

.9 

0 

.8 

16 

.0 

12 

.6 

355 

1  Q1  'i 

35 

g 

40 

.7 

13 

.2 

f, 

.9 

562 

L  J  i  '> 

1913 

Gluten  Biscottes  or  Rolls   . 

51 

.6 

2 

.3 

33 

.0 

29 

.8 

359 

1913 

Gluten  Bread  or  Slices 

54 

.1 

2 

.2 

30 

.9 

27 

.4 

361 

1913 

Gluten  Butter  Biscuits  for  Dia- 

betics     

44 

.1 

33 

.2 

12 

.7 

9 

.0 

526 

1913 

Ginger  Biscuits  for  Diabetics  . 

34 

.6 

39 

.4 

16 

.7 

10 

.9 

560 

1913 

Midolia  Biscuits       .... 

17 

.6 

36 

.4 

31 

.6 

13 

.4 

524 

1913 

Walnut  Biscuits  for  Diabetics 

20 

.9 

57 

2 

12 

.3 

trace 

648 

1913 

Waukesha     Health     Products     Co., 

Waukesha,  Wise.:    Hepco  Dodgers 

41 

.6 

21 

.3 

20 

.7 

trace 

441 

BREAKFAST  FOODS. 

1913 

Brusson  Jeune,  Villemur,  France: 

Farine  au  Gluten     .... 

33 

.9 

0 

.6 

53 

.8 

48 

.8 

356 

1910 

Gluten  Semolina       .... 

17 

2 

0 

.5 

71 

.6 

64 

.9 

360 

1913 

Farwell  &  Rhincs,  Watertown,  N.  Y.: 

Barley  Crystals        .... 

11 

.5 

1 

.3 

75 

2 

62 

.7 

359 

1913 

Cresco  Grits        

17 

.8 

1 

.4 

68 

.6 

54 

.1 

358 

190S 

Hazard's    Wheat    Protein    Breakfast 

Food     

40 

.1 

1 

.0 

49 

.7 

368 

1913 

Health  Food  Co.,  New  York:  Mariana 

37 

.6 

1 

.9 

46 

.8 

31 

.0 

355 

1913 

Jireh  Diabetic  Food  Co.,  New  York: 

Whole  Wheat  Farina     . 

12 

9 

2 

3 

74 

.6 

59 

.5 

371 

1913 

Frumenty      

12 

.3 

1 

7 

77 

.3 

65 

.4 

374 

1911 

The  Kellogg  Food  Co.,  Battle  Creek, 

Mich.:    Granola   

13 

9 

0 

8 

76 

.3 

45 

2 

368 

1911 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Breakfast  Food   . 

37 

8 

1 

3 

51 

.8 

37 

.9 

370 

1911 

Gum  Gluten  Granules  . 

45 

5 

1 

6 

43 

.6 

32 

3 

371 

1901 

Pure  Gluten  Breakfast   Cereal 

43 

7 

1 

6 

44 

.4 

367 

Waukesha     Health     Products     Co., 

Waukesha,  Wise.:  Hepco  Grits.1 

MACARONI,  NOODLES,  ETC. 

1910 

Brusson,  Jeune,  Villemur,  France: 

Pates  aux  Oeufs  Macaroni 

13 

9 

0 

4 

76 

2 

69 

2 

364 

1910 

Pates  aux  Oeufs  Nouillettes     . 

14 

4 

0 

5 

75 

.7 

68 

9 

365 

1913 

Petites  Pates  au  Gluten 

18 

6 

1 

0 

70 

4 

61 

2 

365 

1910 

Vermicelle  au  Gluten     . 

18 

4 

0 

4 

72 

4 

65 

8 

367 

1913 

Jireh  Diabetic  Food  Co.,  Xcw  York: 

Macaroni        

16 

9 

0 

9 

71 

4 

58 

8 

361 

1913 

Eugene    Locb,    New   York: 

Home-made  Noodles 

41 

8 

5 

5 

41 

7 

36 

7 

384 

Said  to  be  identical  with  Waukesha  Hepco  Dodgers. 


f>28 


FOODS  AND   THEIR  COMPOSITION 
TAHLK  224. — (Continued). 


Date 

z 

C.  t 

of 
analysis. 

Manufacturer  and  Brand. 

c 

| 

Z 

£ 

•; 

J 

||  S 

£ 

- 

£ 

- 

0 

5. 

02 

O 

MACAKONI,  NOODLES,  ETC.  —  Cont'd. 

1906 

Pure  Gluten  Food  Co.,  New  York: 

Gum  Gluten  Macaroni 

41 

4 

1 

0 

46 

3 

46.2' 

360 

1911 

Gum  Gluten  Noodles    . 

36 

6 

2 

4 

51 

4 

42  .  0 

374 

PEANUT  BUTTKK. 

1899 

Atlantic  Peanut  Refinery,  Phila.. 

28 

7 

46 

4 

16 

o 

6  .  2 

598 

1913 

.1.    W.    Beardsley    Sons,    New    York: 

Acme  Red  Brand        

28 

2 

48 

3 

15 

2 

4.0 

608 

1913 

Beech-Nut  Packing  Co.,  Canajoharie, 

N.  Y  

29 

4 

46 

6 

16 

0 

4.5 

613 

1913 

A.    C.    Blcnner  &   Co.,    New   Haven 

(distributed  by)    

29 

7 

47 

9 

14 

3 

4.6 

607 

1913 

D.  W.  Brooke,  Newark,  N.  J. 

29 

5 

48 

5 

14 

9 

4.3 

614 

1913 

Dillon  &  Douglass,  New  Haven  (dis- 

tributed by)  :    Perfection 

29 

1 

42 

8 

20 

1 

4.8 

582 

1913 

H.  J.  Heinz  Co.,  Pittsburgh,  Pa. 

28 

9 

47 

3 

15 

2 

4.0 

592 

1913 

The  Kellogg  Food  Co.,  Battle  Creek, 

Mich  

28 

1 

49 

7 

14 

7 

3  .  4 

619 

1913 

Francis  H.  Leggett  &  Co.,  New  York: 

Premier      

29 

7 

43 

7 

18 

8 

6  .  5 

587 

1  9  1  3 

MacLarcn      Imperial     Cheese     Co., 

Detroit    ^lich  *    Flagle 

32 

1 

44 

9 

16 

o 

1  .3 

597 

1913 

Nut     Products     Co.,     New     Haven: 

Penolia 

27 

0. 

51 

3 

13 

o 

3.9 

625 

1899 

Peanolia    Food    Co.,     New    Haven: 

Peanolia     

29 

9 

46 

7 

13 

3 

5  .  6 

593 

1913 

S.    S.    Pierce    Co.,   Boston:     Acharis 

Brand  

28 

7 

48 

3 

14 

G 

5.1 

608 

ALMOND  PASTE. 

1902-3  Chapman,  Chicago  .  . 
1902-3  Henry  Heide,  New  York  . 
1902-3  Spencer,  New  York  .  . 


13.1 

12.7 
13.5 


1913 


NTTS. 
California  Paper  Shell  Almonds  (ed- 

ible portion)  (Lawrence  Co.,  Boston) 
Jireh  Diabetic  Food  Co.,  New  York: 

Diatetic  Pine  Nuts  (Pifinolias)         . 
The  KolloKK  Food  Co.,  Battle  Creek, 

Mich.:  Pine  Nuts       ..... 


MALTKD   NTTS. 
1901       The  Kellojm  Food  Co.,  Battle  Creek, 

Midi.:    Malted  Nuts        .       .       .       .       23. 
1913       Nashville      Sanitarium       Food      Co., 

Nashville,  Tenn.:   Malted  Nut  Food      24. 


1  Determined  by  the  diastase  method,  without  previou>  washing  with  water,  and 
calculated  as  starch, 


COMPOSITION  OF  SO-CALLED  DIABETIC  FOODS 


TABLE  224.— (Continued). 


520 


Date 
of 
analysis. 

Manufacturer  and  Brand. 

J 

£ 

Fat, 
per  cent. 

Carbollydrate, 
per  rent. 

x            C 

OTHER  NUT  PREPARATIONS. 

The  Kellogg  Food  Co.,  Battle  Creek, 

Mich.: 

1913 

Nut    Bromose    (Meltose    and 

Nuts)    

17.1 

26.8 

39.4 

3.2 

467 

1906 

Nut  Butter  (Sanitas)     .      .      . 

28.8 

50.5 

13.9 

9.  11 

625 

1906 

Nut  Meal  (Sanitas)        .      .      . 

29.0 

51.7 

12.1 

8.9' 

630 

1906 

Nuttolene  (Sanitas) 

12.7 

21.8 

6.3 

272 

1906 

Protose  (Sanitas)      .... 

22.6 

9.2 

3.6 

188 

1913 

Nashville     Sanitarium     Food      Co., 

Nashville,  Tenn.: 

Nut  Butter  ...... 

28.0 

52  .  6 

13.0 

3.8 

637 

1913 

Nutcysa  

12.9 

21.0 

6.3 

trace 

266 

1913 

Nutfoda  

20.8 

8.0 

6.8 

trace 

182 

CHOCOLATE. 

1913 

Brusson  Jeune,  Villemur,  France: 

Chocolat  with  Added  Gluten  a  la 

Vanille        

15.9 

49.7 

26.4 

9.2 

617 

1913 

Fromm  &  Co.,  Dresden:    Conglutin- 

Diabetiker-Schokolade    .... 

17.6 

39.1 

32.7 

4.3 

553 

1914 

Karl  Goldscheider,  Carlsbad: 

Feinste    Dessert-Schokolade   f. 

Diabetiker;   "9.98  per  cent. 

carbohydrates"     .... 

11.4 

57.6 

25  .  4 

5.0 

665 

1914 

Feinste    Mocca-Schokolade     f. 

Diabetiker;    "  10.26  per  cent. 

carbohydrates  .... 

10.2 

60.2 

23.5 

4.1 

677 

1914 

Feinste      Nuss-Schokolade      f. 

Diabetiker;    "  11.32  per  cent. 

carbohydrates"    .... 

14.6 

54.4 

23  .  3 

6.9 

641 

1914 

Feinste    Orange-Schokolade    f. 

Diabetiker;   "9.98  per  cent. 

carbohydrates"    .... 

11.4 

57.6 

24.9 

5.0 

664 

1910 

Groetzsch,  Frankfurt: 

Esschokolade  (Orange) 

10.8 

60.7 

17.2 

12.0 

658 

1910 

Kochscholkolade      .... 

25.3 

25.1 

26.1 

15.9 

432 

1903 

Plasmon    Co.,    London:         Plasmon 

Chocolate        .                   .... 

20.2 

25.1 

48.0 

trace 

499 

1903 

Rademann's     Nahrmittelfabrik, 

Frankfurt:     Diabetiker  Chokolade 

17.5 

57.6 

16.9 

3.8 

656 

COCOA. 

1913 

Charrasse  Gluto-Cacao      .... 

21.5 

2<?    9 

40.1 

16.3 

446 

1906 

Jireh  Diabetic  Food  Co.,  New  York: 

Diabetic  Cocoa     

19.1 

18.4 

47.9 

29  .  0 

434 

1903 

Plasmon  Co.,  London:  Plasmon  Cocoa 

52.8 

10.8 

20  .  9 

5.1 

392 

1  Determined  by  the  diastase  method,  without  previous  washing  with  water,  and 
calculated  as  starch. 
34 


f)30 


FOODS  AND   THEIR  COMPOSITION 
TABLE  224. — (Cont inuod). 


Date 

of 

Manufacturer  and  Brand. 

a 

analysis. 

.5  ° 

IR 

CH 

COCOA. — Continued. 
1913       Radcmann's  Niihrmittelfabrik, 

Frankfurt:    Diabetiker-Cacao    .       .       17.6      23.0      44.7   :   10.7 
1913       Callard,    Stewart   &    Watt,    London: 

I     Casoid  Chocolate  Almonds        .      .      22.3     .51.8      10. 1      trace 


MISCELLANEOUS  PKODUCTS. 

1913  CJustav  Muller  &  Co.,  New  York: 
Dr.  Bourna  Sugar-free  Fat-Milk1  . 

1913  1).  Whiting  &  Sons,  Boston:  Sugar- 
free  Milk  (ave.  3  analyses)  . 

1913  Health  Food  Co.,  New  York:  Kaffee- 

brod 

1911  The  Kellogg  Food  Co.,  Battle  Creek, 
Mich.:  Sanitas  Meltose 

1914  Mansfield     Laboratories,     Mansfield, 

Mass.: 

No  name  (square)    .... 
No  name  (hexagonal)    . 

1914      Y  Phospho  "D.  &  D.  Special"     .       . 
Phospho  Food  Co.,  Los  Angeles,  Cal. 


2.4 


29.5 
25 . 4 

13.7 


5.3 
7.2 
1.5 


15.2 


trace 


72.1 


47.  S 
45.5 
79.9 


10.1 


34 . 3- 
31.22 

58 . 0 


402 

020 

57 

88 

355 

291 


370 

358 
300 


E.     DIETETIC  SUGGESTIONS,  RECIPES  AND  MENUS. 

Many  hooks  have  heen  written  containing  recipes  for  diabetic 
patients.  With  modern  methods  of  treatment,  however,  most  of 
these  rules  are  worthless  for  severe  diabetic  patients  because  of  their 
high  content  in  protein  and  fat.  In  general  such  patients  prefer 
and  should  be  encouraged  to  take  simple  natural  foods  rather  than 
artificial  ones. 

The  mild  cases  of  diabetes  need  no  special  recipes.  Desserts 
can  often  be  mack'  with  gelatin  and  this  may  be  flavored  with  coffee, 
lemon,  rhubarb  or  cracked  cocoa.  In  preparing  such  desserts  if 
saccharin  is  used  it  should  be  added  as  late  as  possible  during  the 
cooking  for  it  is  apt  to  become  bitter  with  heat.  It  is  always  a 
safe  rule  to  add  too  little  rather  than  too  much  saccharin.  I'sually 
one  need  pay  little  attention  to  the  quantity  of  protein  in  the  gelatin, 
because  the  ordinary  portion  of  jelly  contains  only  about  2.5  grains. 
One  of  my  patients  on  a  very  rigid  diet  so  enjoyed  the  bulk  of  the 
gelatin  as  to  take  10  grams  daily.  She  accomplished  this  by  having 
the  gelatin  made  very  thick. 


'Water  91.8  per  cent. 

-  Possibly  in  part  due  to  the  copper-reducing  power  of  the  agar-agar  present. 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS         531 

Sea  moss  farina,  and  Irish  moss  are  usually  allowable  for  diabetic 
patients.  Most'of  the  carbohydrate  in  these  materials  is  in  the  form 
of  pentosans  and  galactans,  which  Swartz1  has  shown  to  be  quite 
inert  in  the  body.  Unfortunately  these  products  are  sometimes 
adulterated  with  other  carbohydrates.  This  emphasizes  the  fact 
that  no  matter  how  useful  a  food  may  be  in  itself,  one  must  always 
be  on  the  lookout  for  adulteration. 

Diabetic  Muffins — the  Equivalent  of  an  Egg. — Many  of  the  dia- 
betic flours  are  distributed  with  rules  from  the  manufacturer  for 
cakes  or  muffins.  For  convenience  at  the  Xew  England  Deaconess 
Hospital  we  use  the  following  rules  for  Hepco  cakes  and  Lister 
muffins,  because  if  these  rules  are  followed  one  of  the  cakes  contains 
essentially  the  same  amount  of  protein  and  fat  as  an  egg,  and  so 
can  l)e  interchanged  according  to  the  wish  of  the  patient. 

Recipe  for  Hepco  cakes  so  arranged  that  one  cake  is  equivalent  to 
an  egg: 

Protein.  Fat. 

Hepco  flour,  140  grams 60  29 

Eggs  (2) 12  12 

Cream,  40  per  cent.,  60  c.c 2  24 

Butter,  10  grams 9 

74  74 

Make  twelve  cakes.  Each  cake  contains  (i  grams  protein,  0 
grams  fat,  and  approximately  75  calories. 

Recipe  for  Lister  muffins  so  arranged  that  each  is  equivalent  to 
one  egg: 

Protein.  Fat. 

Lister  flour,  one  box,  60  grams  ....                       42  0 

Eggs  (1) 6  6 

Cream,  40  por  cent.,    45  c.c 2  18 

Butter,  30  grams 25 

50  49 

Make  seventeen  muffins.  Each  muffin  contains  0  grams  protein 
and  (5  grams  fat. 

Bran  Biscuits  for  Constipation, — The  following  rule-  was  given  me 
by  Dr.  F.M.Allen: 

Bran 60    grams 

Salt 1  teaspoonful 

Agar-agar,  powdered 6    grains 

Cold  water 100    c.c.  (J  glass) 

Tie  bran  (for  character  of  bran  to  purchase  see  p.  500)  in  cheese- 
cloth a«nd  wash  under  cold  water  tap  until  water  is  clear.  Bring 
agar-agar  and  water  (100  c.c.)  to  the  boiling-point.  Add  to  washed 

1  Swartz:    Tr.  Conn.  Acad.  Arts  and  Sc.,  1911,  xvi,  p.  247. 


f>32  FOODS  AND   THEIR  COMPOSITION 

bran  the  salt  and  agar-agar  solution  (hot).  Mold  into  two  cakes. 
Place  in  pun  on  oiled  paper,  and  let  stand  half  an  hour;  then,  when 
firm  and  cool,  hake  in  moderate  oven  thirty  to  forty  minutes. 

The  bran  muffins  naturally  will  be  far  more  palatable  if  butter 
and  eggs  are  added.  This  may  be  done  providing  the  patient  allows 
for  this  in  the  diet.  If  the  patient  is  not  upon  a  measured  diet, 
then  considerable  latitude  can  be  employed  in  making  the  bran 

cakes. 

BRAX    CAKES    FOR    DIABETICS. 

Carbo- 

Protoin,  Fat,  hydrate, 

Food.  Amount.  grains.          gnuns.          grains.         C'alorios. 

Bran        ...  2  cups 

Molted  butter    .  30  grains                    .  .              25              .  .              225 

Eggs  (whole)  2  .  .  .                        12              12              .  .              150 

Egg-white  (1)     .  25  grams                     3             .  .              .  .               12 

Halt    ....  1  teaspoonful 

Water. 

15  37  0  393 

Tie  bran  in  cheese-cloth  and  wash  thoroughly  by  fastening  onto 
the  water  tap,  until  the' water  comes  away  clear.  The  bran  should 
be  frequently  kneaded  so  that  all  parts  come  in  contact  with  the 
water.  Wring  dry.  Mix  bran,  well  beaten  whole  eggs,  butter  and 
salt.  Beat  the  egg  white  very  stiff  and  fold  in  at  the  last.  Shape 
with  knife  and  tablespoon  into  three  do/en  small  cakes.  If  desired 
one-half  a  gram  of  cinnamon  or  other  flavoring  may  be  added. 
Each  cake  contains:  protein,  O.o  gram;  fat,  1  gram;  calories,  11. 

Cracked  Cocoa. — Cracked  cocoa  (cocoa  nibs)  makes  a  most,  useful 
drink  for  diabetic  patients.  This  is  not  generally  appreciated  by 
the  profession. 

The  sample  of  cracked  cocoa  (cocoa  nibs)  used  has  been  purchased 
of  the- S.  S.  Pierce  Co.,  Boston.  It  was  analyzed  by  Professor 
Street,  with  the  following  result: 

Moisture 2.  S3 

Protein 14.09 

Fat 51.12 

Fiber 4.32 

Ash 3.88 

Starch        ...             7.48 

Reducing  sugar,  as  dextrose,  direct none 

Reducing  sugar,  as  dextrose,  after  inversion         .             .       .  0.94 

The  cocoa  is  prepared  for  the  table  by  adding  a  cupful  of  the 
cracked  cocoa  to  a  quart  of  water  and  letting  it.  simmer  on  the  back 
of  the  stove  all  day,  adding  water  from  time  to  time. 

Professor  Street  was  good  enough  to  analyze  the  infus'on,  and 
wrote  me:  ''The  cocoa  prepared  according  to  directions  contained 
0.0o2  per  cent,  of  reducing  sugar  as  dextrose  direct  and  O.foJS  per 
cent,  of  total  reducing  sugars." 


DIETETIC  SUGGESTIONS,   RECIPES  AND  MENUS        533 
LEMOX   JELLY    (DIABETIC). 

Carho- 

Protcin,          Fat,  hydrate, 

Food.  Amount.  grams.          grams.          grams.         Calories. 

Lemon  juice     .      .      30  c.c.  .  .  .  .  3  12 

Water   ....     50  c.c. 

Gelatin        .      .      .        4  grams  4  .  .  .  .  16 

Saccharin  (to  sweeten) 

Cream  ....      30  c.c.  1  12  1  116 

5  12  4  144 

Soften  gelatin  in  a  part  of  the  cold  water.  Heat  the  remaining 
\vater  and  lemon  juice  and  pour  over  the  gelatin.  Stir  until  dis- 
solved. Add  saccharin,  strain  into  cups.  Serve  with  cream. 

BAVARIAN   CREAM    (DIABETIC). 

Carbo- 

Protein,  Fat,          hydrate, 

Food.  Amount.  grams.         grams.         grams.         Calories. 

Cream,  40  per  cent.     90  c.c.  3  36  3  348 

Water   ....      10  c.c. 

Egg  (i)       ...     50  grams  6  6  .  .  78 

Gelatin        ...       2  grams  2  .  .  .  .  8 

Saccharin  (to  sweeten) 

Flavoring  (to  taste) 

11  42  3  434 

Soften  the  gelatin  in  cold  water,  then  add  to  the  cream,  which 
has  been  heated.  Stir  until  dissolved,  pour  on  the  beaten  egg,  cook 
like  soft  custard,  turn  into  mold  and  chill. 

ICE   CREAM    (DIABETIC). 

Carbo- 

Protein,          Fat,          hydrate, 
Food.  Amount.  grams.          grams.          grams.         Calories. 

Cream,  40  per  cent.     90  c.c.  3  36  3  348 

Water    ....      10  c.c. 

Egg  (1)       ...     50  grams  6  6  .  .  78 

Saccharin  (to  sweeten) 

Flavoring  (to  taste) 

9  42  3  426 

Make  a  soft  custard  of  the  egg,  50  c.c.  of  the  cream,  and  the 
water.  Whip  the  remaining  40  c.c.  of  cream  and  fold  into  custard. 
The  saccharin  may  be  added  to  the  egg.  The  flavoring  should  be 
added  last. 

Agar-agar  Jelly. — One-quarter  of  an  ounce  sufficient  to  make  one 
quart  of  jelly.  Agar-agar  may  also  be  added  to  broths. 

Miss  E.  Grace  McCullough,  Dietitian  at  the  Peter  Bent  Brigham 
Hospital,  has  given  me  several  practical  suggestions  about  the 
preparation  of  hospital  diabetic  diets.  Many  of  these  have  been 
incorporated  in  what  follows. 

Thrice-cooked  Vegetables. — The  vegetables  are  cleaned,  cut  up 
fine,  soaked  in  cold  water  and  then  strained.  The  vegetables  are 


534  FOODS  AND   THEIR  COMPOSITION 

then  tied  up  loosely  in  a  large  square  of  double  cheese-cloth — large 
enough  so  that  the  corners  of  the  cloth,  after  it  has  been  tied  up 
\vith  a  string,  make  conveniently  long  ends,  and  also  large  enough 
to  allow  the  vegetables  to  swell  without  sticking  together.  They 
are  then  transferred  to  fresh  cold  water,  placed  on  the  fire,  and 
brought  to  the  boiling-point,  at  which  temperature  they  are  main- 
tained for  from  three  to  five  minutes.  This  water  is  then  poured 
oil'  and  replaced  by  fresh,  and  the  vegetables  again  boiled  a  similar 
length  of  time.  Three  changes  of  water  are  usually  sufficient  to 
remove  the  carbohydrate,  as  has  been  proven  by  Professor  Wardall's 
preliminary  experiments.  The  pots  for  the  vegetables  should  be 
of  sufficient  si/e  to  hold  a  large  quantity  of  water,  and  in  a  hospital, 
vegetables  enough  for  the  daily  supply  of  six  patients.  Vegetables 
thus  cooked  will  keep  in  cold  storage  two  or  more  days,  and  the 
reheating  of  the  same  in  a  steamer  is  a  simple  affair. 

If  the  vegetables  are  cooked  with  the  cover  left  off  the  pot  they 
will  be  lighter  in  color  and  the  flavor  not  so  strong. 

Miss  McCullough  has  adopted  several  expedients  by  which 
variety  in  the  5  per  cent,  vegetables  is  obtained,  and  thus  the 
monotony  of  the  diet  avoided.  She  suggests  that  the  large  outer 
stalk — slightly  green  covering — of  cauliflower  be  carefully  cleaned, 
cut  into  half-inch  pieces  and  boiled  until  tender,  and  frequently 
this  is  transferred  from  four  waters.  Similarly,  the  green  outside 
leaves  and  any  small  pieces  of  lettuce  may  be  shredded  and  served 
like  spinach.  Chard  in  season  can  be  purchased  by  the  bushel,  cut, 
and  then  chopped  up.  Rhubarb  retains  its  acid  flavor  and  has 
proven  so  acceptable  an  addition  to  the  diet  that  in  future  it  should 
be  canned  by  the  cold-water  method  for  subsequent  use.  The 
flat,  large,  celery  stalks  with  any  or  all  the  leaves,  whether  yellow 
or  green,  chopped  fine,  serve  excellently  well.  White,  green,  and 
red  cabbage  is  cut  fine  and  served  as  cold  slaw. 

Diabetic  patients  should  be  urged  whenever  possible  to  have 
a  garden  and  to  raise  suitable  vegetables  for  themselves  for  the 
ensuing  winter.  One  of  my  patients  does  this  and  thus  provides 
himself  with  the  best  of  celery,  cabbage,  lettuce,  etc.  This  patient 
eats  a  slice  of  cabbage,  cut  as  one  buys  cheese  in  a  grocery  store, 
for  breakfast  each  morning,  and  by  this  means  keeps  the  bowels 
perfectly  regular. 

Canned  vegetables  which  have  been  of  the  most  service  at  the 
Peter  Bent  Hrigham  Hospital  are  of  four  varieties:  soup  asparagus, 
broad,  flat,  cut  string  beans,  the  tender,  green,  stringless  bean,  and 
the  white  wax  beans.  The  pods  are  separated  from  the  beans, 
the  latter  being  used  for  the  benefit  of  other  patients.  Soup  aspara- 
gus proved  to  be  excellent  for  hospital  use.  It  is  a  by-product  of 
the  factory  and  consists  of  the  broken-off  tips  and  the  shorter 


SEVEN  MENUS  FOR  A  SEVERE  DIABETIC  535 

thin  stalks  which  are  unfit  for  the  standard  size.  The  pieces  are 
about  one  inch  long  and  are  all  edible. 

Squab. — A  squab  when  carefully  boned  yields  50  grams  of  meat. 
This  is  broiled  in  an  oiled  paper  case  to  prevent  evaporation,  and 
when  served  with  the  -escaped  juices  proves  a  favorite  dish  for 
patients.  It  contains  about  12  grams  protein  and  5  grams  fat. 

Boiled  Dinner. — Corned  beef,  with  cabbage  and  one  other  vege- 
table, served  together  as  a  boiled  dinner,  is  most  acceptable  to  male 
patients.  A  portion  containing  50  to  75  grams  of  meat  and  100 
grams  of  each  vegetable  makes  an  excellent  meal.  Corned-beef 
hash  made  of  meat  and  vegetables  in  the  same  proportion  could 
also  be  served  for  variety. 

The  proper  seasoning  of  the  food  is  a  great  help  to  the  diabetic 
patient.  So  many  articles  are  excluded  from  the  diet  that  the 
great  variety  which  is  possible  in  the  preparation  of  the  food  by  the 
help  of  seasoning  is  overlooked.  Horseradish,  to  be  sure,  contains 
10  per  cent,  of  carbohydrate,  but  it  would  take  at  least  two  tea- 
spoonfuls' to  contain  a  gram,  and  probably  far  more.  Sour  pickles 
are  allowable,  and  other  pickles  made  from  the  group  of  5  per  cent, 
vegetables,  provided  one  is  assured  that  they  have  been  prepared 
without  sweetening.  Mint,  capers,  curry,  tarragon  vinegar,  onion 
bay  leaf,  and  cloves  may  all  be  used  as  seasoning,  and  tomato  and 
onion  stewed,  to  which  bay  leaf  and  cloves  may  be  added  and  then 
thickened  with  Irish  moss,  serves  as  a  sauce. 

SEVEN  MENUS  FOR  A  SEVERE  DIABETIC. 

For  the  menus  and  the  recipes  which  make  them  possible  I  am 
greatly  indebted  to  Miss  Alice  Dike,  Instructor  in  Household 
Economics  at  Simmons  College,  and  to  Case  Xo.  7(55.  The 
directions  given  were  as  follows: 

Carbohydrate,      Protein,  Fat, 

Daily  dietetic  prescription.1  gnis.  K'ns.  gms. 

Five  per  cent,  vegetables,  300  grains  10  5  0 

Eggs,  2 0  12  12 

Bacon,  30  grams 0  5  15 

Butter,  30  grams 0  0  25 

Cream,  GO  grams.  40  per  cent.        ...  2  2  24 

Meat,  120  grams 0  32  20 

Lister  roll  (2) 0  12  12 

12  68  10S 

The  calories  furnished  amount  to  about  1200 — a  maintenance  diet 
for  a  patient  weighing  40  kilograms  and  a  sufficient  diet  for  a 
patient  of  50  kilograms  when  in  bed. 

1  These  represented  the  dietetic  orders  for  one  week,  and  from  the  foods  mentioned 
in  the  list  the  menus  which  follow  were  prepared. 


530  FOODS  AND   THEIR  COMPOSITION 


Soft-boiled  egg,  1. 
Fried  bacon,  30  grains. 
Lister  roll  and  butter,  S  grains. 
Coffee  and  eream,  30  grains. 


FIRST    DAY. 
Breakfast. 


Lunch. 


Roast  beef,  GO  grams;  grated  horseradish. 

String  beans,  75  grains,  and  butter,  7  grains. 

Lettuce  and  cucumber  salad,  50  grains. 

Rhubarb  jelly  and  meringue  (rhubarb,  25  grams,  and  2  white  of  egg). 

Dinner. 

Chicken,  GO  grains. 

Cauliflower,  75  grams,  and  butter,  7  grains. 

Celery  and  olives,  75  grains. 

Lister  roll  and  butter,  S  grams. 

Coffee,  Spanish  cream  (egg  1  and  cream  30  grams). 

SECOND   DAY. 

Breakfast. 

Shirred  egg,  1. 

Fried  bacon,  20  grains. 

Lister  roll  and  butter,  S  grams. 

Coffee  and  cream,  30  grams. 

Lunch. 

Roiled  haddock,  GO  grams. 
Cucumber  sauce,  25  grains. 
Rutter,  G  grams. 

Spinach,  75  grams,  and  butter,  8  grams,  and  \  egg. 
Lettuce,  30  grams. 
Coffee  jelly  whip. 

Dinner. 

Lamb  chops,  GO  grams;  tomato  sauce,  45  grams. 
Asparagus,  75  grams  and  butter,  S  grams. 
Dandelion  greens,  50  grains,  and  bacon,  10  grams. 
Lister  cream  puff  and  custard. 

THIRD    DAY. 

Breakfast. 

Egg,  1;  scrambled  with  tomato,  50  grams. 

Bacon,  20  grams. 

Lister  roll  and  butter,  S  grams. 

Coffee  and  cream,  30  grams. 

Lunch. 

Vegetable  hash  (corned  beef,    10  grams;  cabbage1,  NO  grams;  onion,   10  grams; 

beet,  10  grams;  bacon,  10  grams). 
Lett uce,  30  grams. 
Lister  roll  and  butter,  S  grams. 
Tea. 

Dinner. 

Steak,  SO  grams,  and  butter,  7  grams. 

Rroiled  pepper,  25  grams. 

Cauliflower,  75  grams,  and  butter,  7  grams. 

Wine  jelly  and  egg  and  cream  sauce  (egg,  1,  and  cream,  30  grams). 


SEVEN  MENUS  FOR  A  SEVERE  DIABETIC  537 

FOURTH    DAY. 

Breakfast. 

Liver,  40  grams,  and  bacon,  15  grams. 
Lister  roll  and  butter,  10  grams. 
Coffee  and  cream,  15  grams. 

Lunch. 

Ham  omelet  (egg,  1,  and  meat,  20  grams). 

Bacon,  15  grains. 

Salad,  150  grains  (celery,  cabbage,  lettuce). 

Lister  roll,  butter,  10  grams. 

Cracked  cocoa  and  cream,  15  grams. 

Dinner. 

Roast  lamb,  60  grams,  and  mint  sauce. 
Sliced  tomatoes,  75  grams. 
String  beans,  75  grams,  and  butter,  10  grams. 
Vanilla  ice-cream  (egg,  1,  and  cream,  30  grams). 

FIFTH   DAY. 

Breakfast. 

Scrambled  egg,  1,  and  dried  beef,  20  grams. 
Lister  roll  and  butter,  6  grams. 
Coffee  and  cream,  20  grams. 

Lunch. 

Spinach  soup  (spinach,  25  grams;  cream,  15  grams;  yolk  1  egg,  stock). 

Bacon,  30  grams;  fried  with  eggplant,  125  grains. 

Coffee. 

Dinner. 

Steak,  100  grams,  and  water  cress,  25  grams;  "Maitred'Hotel"  butter,  10  grams. 

Vegetable  marrow,  125  grams,  and  butter,  8  grams. 

Lister  roll  and  butter,  G  grams. 

Cracked  cocoa  whip  (white  1  egg  and  cream,  25  grams). 

SIXTH   DAY. 

Breakfast. 

Fried  fish  cakes  and  butter,  G  grams  (fish,  40  grams;  egg,  1;  cream,  15  grams). 
Sliced  cucumbers  on  lettuce,  75  grains. 
Coffee  and  cream,  15  grams. 

Lunch. 

Fried  egg,  1,  and  bacon,  30  grams. 
Lister  roll  and  butter,  10  grams. 
Cold  slaw,  75  grams. 
Tea. 

Dinner. 

Broiled  swordfish,  80  grams  (drawn  butter  sauce,  7  grams,  and  parsley). 

Brussels  sprouts,  100  grams,  and  butter,  7  grams. 

Tomato  jelly  salad,  50  grams. 

Lister  roll  and  whipped  cream,  30  grams  (flavored  with  coffee). 

SEVENTH   DAY. 
Fasting. 


,")3S  FOODS  AM)   THEIR  COMPOSITION 

RECIPES  USED  IN  PREPARING  THE  PRECEDING  MENUS. 

Grated  Horseradish  Sauce. 

1',  teaspoonfuls  grated  horseradish. 

i  teaspoonful  vinegar. 

i  teaspoonful  salt. 
Cayenne. 

2  teaspoon! uls  cream  or  water. 
Mix  first  four  ingredients  and  add  cream  beaten  stiff. 

Cucumber  Sauce. 

(Irate  25  grams  cucumber  and  season  with  salt,  pepper,  and  vinegar. 

Tomato  Sauce. 

Stew  45  grams  tomato,  season  with  salt,  pepper,  clove,  and  bay  leaf.     Irish 
or  sea  moss  may  be  used  for  thickening. 

Parsley  Sauce. 

7  grams  butter. 
1  teaspoonful  chopped  parsley. 
Salt  and  pepper. 
Add  parsley  lo  melted  butter  just  before  serving. 

Mint  Sauce. 

J  cup  finely  chopped  mint  leaves. 
\  cup  vinegar. 
1  grain  saccharin. 

Add  saccharin   to  vinegar  and    dissolve,  pour  over  mint  and  let  stand  thirty 
minutes  on  back  of  range.      Let  cool  before  serving. 

Maitre  d' Hotel  Butter. 

10  grams  butter. 
Salt  and  pepper. 
1  teaspoonful  chopped  parsley. 
i  teaspoonful  lemon  juice. 

Put  butter  in  bowl  and  with  wooden  spoon  work  until  creamy.     Add  seasoning 
and  lemon  juicy  slowly. 

Coffee  Spanish  Cream. 

1    scant    teaspoonful    gelatin    soaked    in    1    tablespoon ful    cold    water    and 

dissolved  in  5  tablespoont'uls  hot  coffee. 

Add  )-!()  grams- cream  and  pour  on  slightly  beaten  yolk  of  egg. 
Cook  liko  soft  custard  and  pour  while  hot  on  stiffly  beaten  white  of  egg. 
Saccharin. 

Rhubarb  Jelly  with  Meringue. 

1  teaspoonful  gelatin  soaked  in  1  tablespoont'ul  cold  water  and  dissolved  in 
sauce  made  by  cooking  rhubarb  in  enough  water  to  make  7  tablespoonfuls. 
Serve  garnished  with  beaten  white  of  egg  flavored  with  vanilla. 
Saccharin. 

Coffee  Jelly  Whip. 

Make  the  same  as  plain  coffee  jelly,  but  just  before  it  hardens  beat  in  an 

egg  beaten   until   fluffy. 
Saccharin. 


RECIPES   USED  IN  PREPARING  PRECEDING   MENUS     530 

Lister  Cream  Puff. 

Lister  biscuit  with  soft  custard  poured  over  it.     The  soft  custard  is  made 

as  follows: 
30  grams  cream. 
\  egg. 

2  tublespoonfuls  water. 
Saccharin  and  flavoring  as  desired. 

Wine  Jelly  with  Custard  Sauce. 

1  scant  teaspoonful  gelatin  soaked  in  1  teaspoonful  cold  water  and  dissolved 
in  4  tablespoonfuls   boiling  water   and   flavored   with   3   tablespoonfuls 
wine  and  saccharin. 
Serve  with  sauce  used  above  for  Lister  cream  puff. 

Cracked  Cocoa  Whip. 

1  scant  teaspoonful  gelatin,  soaked  in  1  tablespoonful  water,  dissolved  in 

5  tablespoonfuls  strong  hot  cocoa. 
When  cooled  to  the  consistency  of  thick  cream,  pour  slowly  on  the  beaten 

white  of  an  egg,  beating  all  the  time.     Mold  and  chill. 

Spinach  Soup. 

25  grams  spinach. 
15  grams  cream. 
Yolk  of  1  egg. 
|  cup  beef  or  chicken  stock. 

Add  stock  to  cooked  spinach  and  cook  five  minutes.  Then  rub  through  sieve. 
Beat  yolk  of  egg  with  cream.  Add  spinach  and  stock  and  return  to 
double  boiler.  Cook  one  minute  and  serve  at  once. 

INEXPENSIVE  MENUS. 
Diet  for  Day. 

Carbohydrate,      Protein,  Fat, 

pins.  grns.  Kins. 

Five    per    cent,    vegetables,    three    times 

washed,  300  grams 0  0  0 

Eggs,  2 0  12  12 

Bacon,  30  grams 0  5  15 

Oleo  or  butter,  50  grams }  Q  041 
Lard  or  crisco,  45  grams  / 

Meat,  120  grams 0  32  20 

Hepco  cakes,  2     .  0  12  12 

0  61  100 

FIRST   DAY. 

Breakfast. 

Fried  egg,  1,  and  bacon,  30  grams. 
Hepco  cake,  1,  and  oleo,  15  grams. 
Coffee. 

Dinner. 
Boiled  dinner. 

Corned  beef,  80  grams. 

Cabbage,  150  grams. 

Oleo,  10  grams. 

Pickle. 

Hepco  cake,  1,  and  oleo,  15  grams. 

Tea  and  coffee. 


540  FOODS  AND   THEIR  COMPOSITION 

Supper. 

Vegetable  and  compel  beef  hash  with  fried  egg: 
Corned  hoof,  40  grains. 
Cabbage,  lf>0  grains. 
Oleo,  10  grains. 
Tea  or  coffee. 

SKCOXD    DAY. 

Breakfast. 

Egg,  1;  scrambled  with  tomato,  50  grams. 
Bacon,  1")  grains. 

Ilepco  cake,  1,  and  oleo,  15  grams. 
Tea  or  coffee.. 

Dinner. 

Hamburg  steak,  SO  grams. 

Onions  (30  grams >  fried  in  10  grams  oleo,  GO  grams. 

Green.s,  90  grains,  with  egg,  1,  and  oleo,  10  grams. 

Hepco  cake,  1,  and  oleo,  15  grams. 

Tea  or  coffee. 

Supper. 

Meat  (liver),  40  grams,  with  bacon,  15  grams. 

Cold  slaw,  100  grams  (cabbage,  vinegar,  salt,  pepper). 

THIRD    DAY. 

Breakfast. 

Boiled  egg,  1. 

Bacon,  30  grains. 

Ilepco  cake,  1,  and  oleo,  15  grams. 

Coffee,'. 

Dinner. 

Boiled  cod,  SO  grants,  with  oleo,  10  grams,  and  vinegar. 
String  beans,  150  grams,  and  oleo,  10  grams. 
Hepco  cake,  1,  and  oleo,  15  grains. 

Supper. 

Sardines,  40  grams,  with  hard-boiled  egg,  1. 
Sauerkraut,  150  grams. 
Tea  or  coffee. 

PICNIC  LUNCHES. 

FIRST    DAY 

Dinner. 

Lister  sandwich:    1  Lister  roll,  chicken,  (JO  grains,  cucumber,  75  grams. 

1  lard-boiled  egg. 

Olives. 

Tea  or  coffee. 

Supper. 

Sardines,  (JO  grams. 
Lister  roll  and  butter. 
Lettuce,  radish,  and  celery,  75  grams. 
Ripe  tomato,  50  grams. 


RECIPES   USED  IN  PREPARING  PRECEDING  MENUS    541 

SECOND   DAY. 

Dinner. 

Sliced  veal  loaf  sandwiches  (1  Lister  roll). 
Dressed  cabbage,  75  grams. 
Custard  (-J-  egg). 
Coffee. 

Supper. 

Salad  (cold  halibut,  egg,  \,  cucumber,  75  grams). 
Lemon  or  rhubarb  jelly. 
Brazil  nuts. 

THIRD    DAY. 

Dinner. 

Cold  lamb  chop. 
Tomato. 

Olives  and  pickles. 
Lister  cream  puff. 

Supper. 
Salad:   egg. 

Lister  sandwich:   Lister  roll,  cold  bacon,  lettuce. 
Coffee  Bavarian  cream. 

FOURTH   DAY, 

Dinner. 

Egg  baked  in  tomato  with  cheese  on  top. 
Ham  sandwich:    1  Lister  roll. 
Swiss  chard. 
Coffee  jelly. 

Supper. 

Sandwich:   cold  roast  beef,  1  Lister  roll,  lettuce  and  horseradish. 
Rhubarb  sauce. 


542 


FOODS  AX1)   THEIR  COMPOSITION 


G.     TABLES  OF  EQUIVALENTS. 

TABI.K  225. — COMPARATIVE  SCALES  OF  KILOCKAMS  AND  POUNDS,  CENTIMETERS 

AND   INCHES. 

(I  am  indebted  to  Mr.  Edward  Clark,  of  (he  Massachusetts  Institute  of  Technology, 
for  the  preparation  of  these  scales.) 


Kilograms  to  pounds.                                                    OntimrtiTs  t,  >  frr-t  and  inc 

Kg.        Lb.                  Kg.         Lb.                   Kg.          Lb.                               Cm.     ^_  hi.  Ft. 

20— 

-41                       rM~I 

-110                     125- 

200- 

ou 

. 

-43 

-270 

10 

—  42 

-105                    120- 

190- 

-75 

- 

41 

115- 

— 

—6 

is 

-40                      45~ 

-100 

-  250                                    180  -: 

—  70 

-39 

no- 

O"» 

-210 

: 

17 

—its 

170- 

- 

i 

—  37 

105- 

-  230 

-65 

—30 

—  90 

i 

16 

—35                      W~ 

100- 

—  220                                     1GO" 

- 

- 

-34 

—  So 

—  210 

—GO—  5 

— 

95- 

150 

15 

-33 

^_ 

—32 

90- 

-200 

- 

11 

-31                     35- 

140- 

—  55 

-190 

— 

-30 

-  75                      35  - 

— 

-29 

- 

130 

13  - 

_ 

—  ISO 

- 

1 

— 

SO 

-50 

: 

—28 

iO 

_ 

-27 

170 

—4 

120  - 

12 

30  — 

75 

-26 

-  (15 

~ 



— 

100 

- 

-45 

- 

-25 

70- 

- 

.— 

- 

110 

_ 

11  — 

—24 

-  (JO 

150 

-     — 

-23 

(W 

—                                              — 

- 

- 

110 

-40 

1(1 

-22                      '~~>~ 

-  55 

10(1 

- 

_ 

-21 

150- 

- 

- 

130 

— 

_ 



- 

—  3 

~ 

—  20 

-  50 

DO— 

— 

•*  _ 

-35 

_ 

-                                  

55  ~ 

- 

_ 

120 



- 

-19 

_ 

- 

- 

—  32 

—  18 

-     15 

8  — 

20  — 

50~ 

-110                                  80~ 

Kg.         Lb.                  Kg.          LD.                   Kg.          Lb.                                 Cm.         In.  Ft. 

EQUIVALENTS   USEFUL  IN  DIABETIC  WORK  543 

EQUIVALENTS  USEFUL  IN  DIABETIC  WORK.1 

TABLE  226. 

1  gram     O2  (T.  =  0°  C.     Tension,  760  mm.  mercury)  =  0.7        liters. 
1  gram  CO2  (T.  =  0°  C.     Tension,  760  mm.  mercury)  =  0.5091  liters. 

1  liter      O2  (T.  =0°  C.     Tension,  760  mm.  mercury)  =  1.4285  gm. 
1  liter    CO2  (T.  =0°  C.     Tension,  760  mm.  mercury)  =  1.9642  gm. 

According  to  Zuntz2  the  quantity  of  oxygen  which  has  been 
used  and  the  quantity  of  carbon  dioxide  which  has  been  produced 
in  the  combustion  of  protein  represented  by  the  excretion  of  1 
gram  of  urinary  nitrogen  is,  at  0°  C.  and  a  pressure  of  700  mm. 
Hg,  as  follows: 

1  gram  urinary  nitrogen  equivalent  to  8.44  grains     O2,  or  5.91  liters. 
1  gram  urinary  nitrogen  equivalent  to  9.33  grams  CO2,  or  4.75  liters. 


1.0  ounce 28.4    grams 

1.0  pound 454.0        " 

2.2  pounds 1.0    kilogram 

1  fluidounce 29.6    cubic  centimeters 

1  quart 946.0 

1000  grams 1.0    kilogram 

1000  cubic  centimeters 1.0    liter 

1.0  meter 39. 37  inches 

1000.0  meters 3281. 00  feet 

1609.3  meters  5280.00  feet  or  1  mile. 


1  horizontal  kilogram-meter  requires  expenditure  of  0.0005  calorie. 
426.5  vertical  kilogram-meters  represent  the  heat  equivalent  of  1  calorie. 

'See  also  Tables  39,  40,  41,  42,  103,  105,  109,  110,  111,  112,  120,  124. 

•  Zuntz  u.  Schumburg:   Physiologic  des  Marsches,  Berlin,  Hirschwald,  1901,  p.  361 


CASE  INDEX.1 


Case        I .     Reason  for  not  giving  drugs 399 

4.     Severe  acidosis .         158,  164 

1500  c.c.  alkaline  solution  temporarily  brought  out  of  coma  .  397 

7.  Trauma 62 

8.  Tendency  of  glycosuria  to  increase          83 

Volume  of  urine  little  index  to  severity              170 

Negative  carbohydrate  balance  due  to  stored  carbohydrate  27.5 

Prolonged  use  of  high  fat  diet 278 

Intermittent  claudication  preceded  hemiplegia       ....  418 

"          10.     Disadvantage  of  treatment  with  drugs;  description  of  case    .  400 

11.     Angina  pectoris;  sudden  death 418 

17.  Apparent  tolerance  for  milk 377 

18.  Gall-stones 295 

29.     Operation  for  appendicitis 342 

"          30.     Importance  of  examining  mixed  twenty-four-hour  specimen 

of  urine          169 

38.     Specific  gravity  not  always  high  in  presence  of  sugar        .      .  173 

58.     Gangrene  of  long  duration  after  amputation 423 

70.     Blood-pressure  fell  with  diet ;  complication  of  gangrene    .      .  417 

"         90.     Success  of  treatment  in  diabetic  of  advanced  years     .      .      .  468 

"        102.     Successful  pregnancies 449 

"       105.     Survived  mumps 326,  403 

"        106.     Pregnancy  with  severe  diabetes;  healthy  child        ....  452 
"       127.     Temporary     disappearance     of     sugar     with     removal     of 

fibroid 296,  447 

"        129.     Temporary  precedes  permanent  diabetes 286 

"        135.     Loss  of  weight  on  withdrawal  of  sodium  chloride         .      .      .  127 
155.     Mother  of  Case   Xo.   203,  in  whom  diabetes  was  apparently 

cured 52 

"        173.     Operation  at  seventy-three  years,  later  cerebral  hemorrhage 

with  unusual  recovery 445 

"        181.     Intermittent  fasting;  my  first  case  so  treated 314 

Description  of  case,  with  dietary  and  urinary  charts  .      .      .  493 

"        190.     "Is  tendency  of  untreated  glycosuria  to  increase?"     ...  84 

"        194.     Gain  in  tolerance  when  sugar-free 85 

1  In  the  Case  Index  are  not  included  references  to  those  cases  mentioned  in 

Tables  30,  36,  49,  81,  82,  85,  90,  91,  100,  101,  108,  139,  140,  147,  148,  149,  174, 
175,  180,  181,  183,  185,  195,  205,  and  206, 

35  ( 545 ) 


540  CAKE    INDEX 

Case    2015.     Favorable  influence  of  heredity 52 

220.     Unset  of  coma  after  Castro-intestinal  attack 1C>4 

"        234.     Died  with  cardiac  incompctcncy .  419 

"       23").     Loss  of  energy  in  excretion  of  sugar  and  acid  bodies     .      .      .  147 

Temporary  precedes  pennanent  diabetes 280 

24t>.     Decrease  in  acidosis  after  oatmeal 374 

"        252.     Coma  upon  restriction  of  diet .  1(14 

"        289.      Decrease  in  acidosis  after  oatmeal .       .  37/5 

2l.)f>.      Large  amount  of  urine  and  sugar      ...             ....  1/57 

Exceptionally  long  duration 4(>3 

"       304.     Coma  following  active  exercise 21)1 

307.      Pregnancy    with    severe    diabetes  and    albumin    and    casts; 

patient    survived,  child  lost 452 

309.  Call-stones 295 

Pregnancy  case  with  small  amount  sugar 448 

310.  Typical  onset  of  coma 1C>4 

318.      Pregnancy  case;  small  amount  of  sugar:  favorable  outcome  44!) 

332.      KlTect  of  levulose  and  oatmeal  on  respiratory  quotient     .       .  143 

"        340.     Volume  of  urine  little  index  to  severity        .       .             ...  170 

343.  Loss  of  both  legs  from  gangrene 423 

344.  Loss  of  energy  in  excretion  of  sugar  and  acid  bodies  .      .    lf)8,  253 

Excretion  of  ammonia 189 

Minus  carbohydrate  balance         .       .                                       .       .  27t) 
Carbohydrate   balance1  and  acidosis   in   relation   to  oatmeal 

days ....   282,  374 

Disappearance  of  acidosis  with  development  of  tuberculosis  2!)7 

Diabetes  and  tuberculosis 40!) 

"        347.     Renal  involvement 170 

Left  hospital  in  good  condition;  coma  shortly  after     .             .  304 

Arteriosclerosis 41!) 

"        348.     Operation  for  removal  of  prostate 70,  442,  447 

Constipation  relieved  by  sawinii  wood 434 

"Is  tendency  of  untreated  glycosuriu  to  increase?'1     .             .  84 

Improvement  with  diet 2!) 

KiTect  of  development  of  nephritis 53 

Cardiac  incompetcncy       .      .                                    ....  41!) 

355.     Angina  pectoris 311 

Cangrene 423 

35t>.      "Is  tendency  of  untreated  glycosuna  to  increase?"    .             .  84 

371.      Decrease  in  acidosis  after  oatmeal     .             ....             .  374 

43C>.      Niece  of  patient  with  marked  heredity         47 

Description  of  case;  notable  increase  in  tolerance  for  carbo- 
hydrate <luring  pregnancy         .  455 

441.      Decrease  in  acidosis 375 

443.     Tuberculosis      .            408 

457.     Nephritis 53 

47)5.      Importance  of  examining  mixed  twenty-four-hour  specimen 

of  urine 169 

Neglected  hereditary  case  with  gradual  onset 300 

Developed  coma  on  beginning  treatment 304 


CASE    INDEX  547 

Case    488.     Importance  of  examining  mixed  twenty-four-hour  specimen 

of  urine 169 

"       499.     Death  due  to  angina  pectoris 341 

"       513.     Loss  of  weight  caused  by  loss  of  body  fluid 73 

Gain  in  weight  while  fasting  and  taking  mineral  water     .      .  127 

Increase  in  sugar  following  administration  of  fat   ....  277 

D  :  N  ratio 299 

Description  of  case;  carbuncle  and  septicemia        ....  353 

"       521.     Carbohydrate  tolerance  fell  with  attack  of  herpes  zoster        .  404 

"       533.     Acute  appendicitis 44G 

"       542.     Appendicitis;  coma 446 

"       552.     Effect  of  levulose  on  respiratory  quotient 143 

Severe  diabetes  changing  to  moderate 297 

"       559.     Removal  of  prostate  at  seventy-five  years  of  age  ....  447 

"       564.     Description  of  case;  large  amount  of  fat  in  diet     ....  278 

"       585.     Polyuria  not  always  unfavorable  omen        .      .            ...  171 

"       597.     Removal  of  cataract 438 

u        599.     Removal  of  prostate  under  gas  and  oxygen 447 

"       604.     Pregnancy  case;  neglect  of  treatment;  uremic  coma    .      .      .  452 
"       608.     Pregnancy  case;  neglect  of  proper  treatment;  coma    .      .      .  452 
''       610.     Persistence  of  sugar  with  vulval  abscesses  ...            .      .  314 
Description  of  case;  prolonged  fasting;  variations  in  tolerance  3o6 
"       629.     Angina  pectoris,  tuberculosis,  old  age  and  diabetes  with  fail- 
degree  of  health 404,  407,  468 

Blood-pressure  fell  with  treatment  of  diabetes       ....  418 
"       632.     Description  of  case;  treatment  with  levulose    ....    382,  393 

"       633.     Tuberculosis  first  discovered  at  autopsy 407 

"       670.     Tolerance  for  fat  in  connection  with  pancreatic  diabetes        .  276 

"       671.     Pregnancy;  abortion;  suicide 454 

"       687.     Success  of  treatment 468 

"       697.     Two  operations  for  gall-stones 438,  443 

"       698.     Pregnancy  case;  favorable  course  with  restricted  diet     .      .  449 

"       714.     Lowered  respiratory  quotient  when  sugar-free        .      .      .      .  118 

"        721.     Removal  of  uterine  fibroids 447 

"        727.     Blood-pressure  fell  with  disappearance  of  sugar     ....  417 

''        729.     Death  following  ether  anesthesia 70 

Extraction  of  teeth  with  ether 164,  431 

Pregnancy  case 449 

"        733.     Mild  obese  case  quickly  sugar-free 313 

High  fat  and  low  carbohydrate  diet ;  death 346 

"        753.     Appendicitis 341 

Teeth  extracted  with  gas  and  oxygen 431 

"       759.     Jewish  case  with  marked  heredity 47 

Angina  pectoris       ...             341 

Acidosis  on  fat-protein  diet 422 

Description  of  case;  dietary  and  urinary  charts      ....  489 

"       765.     Effect  of  potato  on  respiratory  quotient 143 

Showers  of  casts;  not  necessarily  fatal 200 

Favorable  change  in  carbohydrate  balance 276 

Long  periods  of  fasting;  relieved  by  broths 312 


548  CASE    INDEX 

Case    765.     Intermittent  fasting;  description  of  case  and  chart      .      .      .  314 

Exceptional  tolerance  for  fat 320 

Increased  number  of  calorics  consumed  with  severe  acidosis  321 

Drainage  of  alveolar  abscess 326 

"        773.     Effect  of  oatmeal  on  respiratory  quotient 144 

"       770.     Metastases  from  carbuncle;  death 420 

"        783.     Could  eat  liberal  carbohydrate  meal  with  impunity  if  exer- 
cised strenuously  afterward 292 

"       785.     Death  from  inanition 09 

Effect  of  levulose  on  respiratory  quotient 135,  143 

Lack  of  exercise 462 

"       780.     High  blood  fat Frontispiece,  100,  206,  472 

Death;  treatment  with  radium 217 

"       791.     Pregnancy  case  with  small  amount  of  sugar 449 

"        799.     Onset  at  eighty-three  years;  shunned  fasting  and  rightly       .  311 

"        806.     Effect  of  potato  on  respiratory  quotient 143,  144 

Syphilis 364 

Retrobulbar  neuritis 438 

"       812.     Pregnancy  with  favorable  outcome 449,  450 

u       813.     Tonsillitis 68,  312 

Child  of  seven  years  tested  own  urine 302 

Broke  over  rules,  with  fatal  result 459 

"        814.     Course  of  disease  in  child  of  twelve  years 463 

"        833.     Removal  of  prostate  with  spinal  anesthesia 447 

"        836.     Diphtheria 71 

Coma 164 

"       854.     Multiple  pregnancies 452 

"        855.     Death  due  to  appendicitis 352 

Gangrenous  appendix 446 

"        859.     Circulation  affected  by  marked  changes  in  diet      ....  420 

"        861.     Improvement  in  tuberculosis 407 

"       865.     Unsuccessful  case  in  little  child 310 

Fat-protein  diet 350 

"        869.     High  blood-pressure  and  goitre 308 

Carcliorenal  complication 362 

872.     Nephritis      .  53 

"       8S7.     Duration,  twenty-nine  years 40,  307 

Case  unsuccessfully  treated;  description  of  case     ....  359 

"        894.      Dietary  chart  of  child  of  three  years 466 

"        895.     (Jangrene  subsequent  to  pneumonia        ....  423 
"        901.      Understands  significance  of  positive   Benedict    test    at   four 

years  of  age •  302 

"       904.     Rise  in  blood  sugar  with  carbohydrate 95 

Death  from  carbuncle- 329,350,430 

High  blood  sugar    .             469 

"        910.     Tuberculosis;  temperature  chart 406 

"       923.     Good  effect  of  exercise;  fasting  treatment    .      .  462 

Description  of  case;  dietary  and  urinary  charts      ....  4S4 
"        925.     Good  effect  of  exercise;  illustration  of  fasting  treatment  in  a 

child                                                                            ....  462 


CASE   INDEX  549 

Case    927.     Poor  treatment  of  diabetes  of  long  duration;  acid  poisoning  348 
"       938.     Gradually  became  accustomed  to  fat  in  diet     .      .      278,  280,  461 

Infection  of  upper  air  passages 312,  400 

Description  case;  dietary  and  urinary  charts 485 

"       941.     Change  in  water  content  of  body 421 

"       942.     Ferric  chloride  test  positive  after  use  of  a  brand  of  saccharine 

combined  with  sodium  bicarbonate 395 

"       950.     Dietary  chart  of  child  of  two  years 406 

951.     Pyorrhea 326 

"       954.     Multiple  etiology;  description  of  case 60 

"       965.     Intercurrent  infection 312 

"       974.     High  fat  and  low  carbohydrate  diet;  left  hospital  in  good 

condition;  went  into  coma 304,  345 

"       978.     Importance  of  examination  of  twenty-four-hour  specimen 

of  urine 169 

"       979.     Case  of  woman  of  forty-nine,  onset  at  thirty-two;  sugar-free 
with  elimination  of  fat,   restriction   of   protein;   gradual 

diminution  of  carbohydrate 307 

982.     Trauma 62 

Extensive  use  of  salt 170,  284 

"       983.     Diabetes  clinically  severe,  but  with  treatment  moderate,  in 

fat  patient  with  acidosis 344 

"       995.     Child  glories  in  good  Benedict  test 302 

Dietary  chart  of  child  of  six  years 466 

"       997.     Dietary  chart  of  child  of  eight  years 466 

"     1004.     Blood  lipoids  in  coma 105 

Fat-protein  diet;  neglect  proper  treatment 343 

"     1005.     Treatment  abandoned;  danger  of  self-treatment    ....  347 
"     1007.     Diabetes  of  fifteen  years'  duration;  sugar-free  in  three  days 
by  elimination  of  fat,  restriction  ofiprotein,  gradual  dimin- 
ution of  carbohydrate 308 

"     1008.     Temporary  precedes  permanent  diabetes 286 

"     1015.     High  blood-pressure  with  suppression  of  urine       ....  87 

"      1017.     Pregnancy  case  with  small  amount  of  sugar 449 

"     1018.     Pregnancy  case  with  large  amount  of  sugar 449 

"      1019.     Death  following  drainage  of  bladder;  acute  cardiac  dilatation  341 

"     1025.     Prolonged  fasting 308 

"     1053.     Gangrene;  CO2  in  blood  21  mm.  Hg 215 

Low  excretion  of  salt  in  coma 285 

"     1058.     Case  with  acute  onset;  death  five  months  after  leaving  hos- 
pital; high  fat  and  low  carbohydrate  diet      ...             .  345 
"      1062.     Practically  fasted  by  home  physician  twenty-six  years  ago    .  323 

"     1070.     Cesarean  section 217 

Pregnancy  case  with  large  amount  of  sugar 449 

Description  of  case 457 

u      1085.     Death  from  inanition;  description  of  case 68,  340 

"      1086.     Drainage  of  bladder;  non-protein  nitrogen  in  blood     .      .    173,  211 

"      1094.     Sugar-free  with  gradual  restriction  of  diet 251 

"      1100.     Sugar-free  with  moderate  diet 253 

"     1114.     Sugar-free  with  difficulty;  low  CO2  in  blood  plasma    .      .      .  217 


550  CASE    INDEX 

Case  1120.     Death  from  inanition;  description  of  case 69,338 

Alveolar  air 233 

Increase  in  sugar  following  administration  of  fat   ....      277 
"     1130.     Development  of  diabetes  with  obesity  in  child       ....       53 

"      1142.     Obesity  as  etiological  factor 54 

"     1143.     High  retention  of  non-protein  nitrogen  in  blood     ....     211 

Neglect  ])ro))er  treatment 343 

"     1147.     Estimated  diet  prior  to  treatment     Example  of  the  untreated 

diabetic  as  a  food  spendthrift 2f>3 

Estimated  more  comfortable  upon  reduced  diet    ....     254 

"     Hoi.     Large  volume  of  urine;  description  of  case 171 

"     1157.     Sugar  appeared  with  responsibility 290 

"      11SS.     Indirect  harm  from  trauma 03 

"      1191).     Large  volume  of  urine  when  sugar-free 170,283 

Marked  acidosis,  but  disappeared  without  alkalis        .      .   217,  390 

Metabolism  of  protein  while  fasting 208 

Intermittent  fasting 314 

Description  of  case  treated  with  levulose     .      .      .       3 1C),  379,  393 

"      1199.     Chart  of  child  two  years  old 403 

"      1209.     Chart  of  child  who  conquered  tendency  to  eat  candy       .      .      402 
"      1213.     Description  of  case  treated  with  levulose;  girl  of  seventeen 

years 320,  384 

"      1220.     Not  severe  case,  but  continual  excretion  of  a  little  sugar       .      298 

"     122S.     Inadequate  measure  of  fat  tolerance 321 

"      1233.     Description  of  case  treated  with  levulose 320,  385 

Condition  of  kidneys  as  shown  by  phenolphthalein  excretion     423 

"      1237.     Illustration  of  ambulatory  treatment 300 

Easily  became  sugar-free  with  protein  at  normal  level     .      .     311 

"      1239.      Drainage  of  abscess  of  lung 320,  342 

Changes  in  pulmonary  epithelium  in  relation  to  alveolar  air     239 

"      1204.     Tonsillitis 403 

"      12i')7.     Treatmentwithlevulo.se  .  ....     314 

"     1287.    Feels  better  if  keeps  under  limit  of  carbohydrate  tolerance     .     325 


INDEX. 


ABBREVIATIONS,  485 

Abscess  of  lung,  operation,  recovery, 

443 

Acetone  and  diacetic  acid,  quantitative 
test  for,    191, 
196 
Huppert-Mess- 

inger,  191 
in  blood,  214 

Wishart's  test  for,  214 
qualitative  test  for,  185 
quantitative  test  for,  194 
Acid  bodies,  elimination  of  source  of 

supply,  392 

mode  of  elimination  of,  156 
percentage    relation    to    one 

another,  155  • 
source  of,  155 

substances  favoring  combus- 
tion of,  392 
intoxication,  treatment  of,  387 

alkalis  in,  dangers  of,  394 
Acidosis,  culmination  of,  in  coma,  164 
dependence  upon  fat  in  diet,  281 
in  diabetes,  similarity  to  that  in 

normal  individuals,  156 
during  fasting  of  a  fat  woman,  152 
effect  of  oatmeal  cure  on,  374 
induced     in     normal     individual, 

influence  of,  111 
in  mild,  severe  and  extreme  cases 

of  diabetes,  157 
nature  of,  148 
qualitative  tests  for,  185 
quantitative  tests  for,  186 
relation  to  coma,  148 
safeguards  of  body  against,  161 
treatment  of,  results  of,  234 
upon  a  fat-protein  diet  of  a  normal 

individual,  153 
variation  of,  with  age,  163 

with  condition  of  kidneys,  163 
with  onset,  163 
Agar-agar,  533 
Akoll,  525 

Albumin,  tests  for,  200 
Alcohol  in  coma,  393 
in  diabetes,  282 


Alcohol,  effect  of,  on  body  processes, 

223 

respiratory  quotient  for,  227 
Alimentary  glycosuria,  17 
Alkalinity  of  blood,  titratable,  test  for, 

222 

Alkalis,  dangers  of,  394 
Allen's  hypothesis  of  diabetes  mellitus, 

76" 

paradoxical  law,  18 
Almond  paste,  528 

Alveolar  air,  carbon  dioxide  tension, 231 
Fridericia  meth- 
od, 233 
25    mm.   Hg  or 

less,  234 
Marriott's 

method,  237 

Ambulatory  treatment,  500 
Ammonia,   method   for  determination 

of,  188 
Anesthesia,  441 

in  diabetes,  70,  350,  431,  438 
without  subsequent  acidosis,  432 
Appendicitis,  446 

death  caused  by,  352 
Arteriosclerosis,  diabetes  mellitus  and, 

62,  413 
Aspirin,  401 

Assimilability  of  dextrose,  257 
of  galactose,  258 
of  inulin,  259 
of  lactose,  258 
of  levulose,  258 
of  maltose,  258 
of  saccharose,  258 
of  starch,  254 


B 


BACOX,  248,  249 

loss  of  weight  during  cooking  of, 

24S 
Bananas,  510 

carbohydrate  in.  266 
in  treatment  of  diabetes,  377 
Bang's  method  of  estimation  of  blood 

sugar,  204 
Barley,  510 

(551) 


INDEX 


Beef,  508 

Benedict's  qualitative  test,  175 

quantitative  test,  180 
Blood,  acetone  in,  214 

Wishart  test  for,  214 
alkalinity  of,  tit  rat  able  test  for,222 
chlorides  in,  test  for,  212 
examination  of,  202 
hydrogen-ion  concentration  in,  221 
lipoids  in  diabetes,  100 
in  health,  90 

influence  of  carbohydrate  bal- 
ance on,  104 
fasting  on,  103 

in  normals  and  diabetics  com- 
pared, 100 
test  for,  200 

non-protein  nitrogen  in,  208 
plasma,  carbon  dioxide  in,  test  for, 

214 

Van  Slykes',  217 
solids  of,  total,  223 
sugar,    as    clue    to    character  of 

disease,  91 
during  treatment,  93 
effect  of  dextrose  on,  257 
estimation  of  Bang's  method, 

204 
Lewis-Benedict    method, 

203 

influence  of  carbohydrate  bal- 
ance on,  91 
duration  of  diabetes  on, 

90 

excretion  of  sugar  in  pre- 
ceding        twenty-four 
hours     on,     91 
in  severe  diabetes,  92 
threshold,  91 

Van  Slyke-Fitz  method,  194 
Body  protein,  storage  of  carbohydrate 

as,  139 

Boiled  dinner,  535 
|3-oxybutyric  acid  in  blood,  190 

quantitative  tests  for,  190 
Black's,  190 
Shaffer's,  190 
diacetic  and  acetone  in  urine  and 

blood,  194 

Bran  biscuits  for  constipation,  531 
Bread,  510 

bran,  505,  531 
carbohydrate  in,  207 
Breads,  gluten,  500 
hard,  523 
light,  500 
soft,  522 

substitutes  for,  505 
Breakfast  foods,  527 
Bright's  disease,  diabetes  mellitUS  and, 

419 
Broths,  271,  284 


Broths,  analyses  of,  272 
Buckwheat  flour,  510 
Butter,  509 
Buttermilk,  510 


CALORIC  needs  of  children,  243 
in  diabetes,  251 
of  diabetic,  321 
in  health,  240 
values  which  every  doctor  should 

know,  249 
Calories,  lost,  322 
Cancer,  deaths  from,  in  1910,  342 
Caramel,  401 

Carbohydrate,  assimilability  of,  254 
balance,  141,  275 
in  bananas,  200 
in  bread,  207 
content  of  foods,  511 
in  diabetic  diet,  estimation  of,  259 
effect  of  exercise  on,  144 

in  prevention  of  coma,  393 
in  fruit,  204 
in  grapefruit,  200 
increased     assimilability     of,      in 
absence  of  fat,  273 
of  protein,  273 
influence  of  rate  of  administration 

of,  138 

in  lemons,  200 
in  milk,  207 
in  nuts,  204 
in  oatmeal,  207 
in  oranges,  204 
possible  storehouses  for,  139 
in  potatoes,  203 
in  relation  to  weight,  141 
respiratory  quotient  for,  220 

following  ingest  ion  of,  142 
in  ripe  olives,  2(50 
storage  of,  as  blood  sugar,  130 
body  protein  and,  139 
as  glycogen,  135 
tolerance  for,  determination  of,  317 

improvement  in,  391 
utilization  of,  140 
in  vegetables,  259 

Carbohydrates,  gain  in  tolerance  for,  84 
influence  of,  on  weight,  125 
storage  of,  in  diabetes,  134 
Carbon  dioxide  in  blood  plasma,  test 

for,  214 

tension  of  alveolar  air,  231 
Carbuncles  in  diabetes,  429 

multiple,  death  caused  by,  353 
Cardiorenal        complications,        death 

caused  by,  302 
Casoid,  523 
Casts,  200 

"showers"  of,  201 


INDEX 


553 


Cataracts,  438 
Cereal,  coffee  infusion,  511 
Cesarean  section.  453,  457 
Chart,  dietary  and  urinary,  481 

history,  diabetic,  480 
Cheese,  509 

Children,  diabetes  in,  52,  458 
fat  requirement  of,  461 
healthy,  nitrogen  and  salts  in  urine 

of,  460 

protein  requirement  of,  460 
Chlorides  in  blood,  test  for,  212 

in  urine,  test  for,  201 
Chocolate,  511 

and  cocoa,  529 
Cholesterol,  96,  99 

and  blood  sugar  compared,  107 
esters,  97 
Clams,  509 
Classification  for  prognosis,  299 

for  treatment,  297 
Cocoa,  511 

cracked,  532 
Coma,  alcohol  in,  393 

carbohydrate  in  prevention  of,  393 
deaths  from,  in  1916,  342 
with,  causes  of,  69 
ether,  70 

impaired  kidneys,  70 
infections,  71 
influence  of  fat-pro- 
tein diet  in,  72 
mental     excitement, 

72 
rapid    loss    of    body 

fluid,  73 

without,  causes  of,  65 
cancer,  67 
cardiorenal,  67 
inanition,  68 
infections,  68 
pernicious  anemia, 67 
suicide,  67 
tuberculosis,  67 
vascular,  67 

liquids  in,  importance  of,  397 
loss  of  weight  during,  129 

prior  to,  129 

relation  of,  to  acidosis,  148 
treatment  of,  results  of,  388 

of  threatening,  387 
Conjugal  diabetes,  49 
Conservation  of  energy  in  a  diabetic, 

398 

Constipation,  bran  biscuits  for,  531 
in  diabetes,  433,  475 
exercises  for,  434 
Cornmeal,  510 
Crabs,  509 
Crackers,  510 
Cream,  510 
Crockery,  diabetic,  251 


DANGER  zone,  diabetic,  303 

Death,  average  age  at,  in  United  States, 

25 

with  coma,  causes  of,  69 
without  coma,  causes  of,  65 
Deaths,  causes  of,  in  191(5,  338 
Dextrose,  antidiuretic,  in  health,  19 
assimilability  of,  257 
diuretic,  in  diabetes,  19 
effect  of,  on  blood  sugar,  257 
nitrogen  ratio,  130,  274 

in  excess  of  3.65  to  1,  133 
Diacetic  acid,  qualitative  test,  for,  185 
Diabetes  mellitus,  alcohol  in,  282 
Allen's  hypothesis  of,  76 
apparent  increase  of,  due  to 
more  accurate  statistics,  25 
appendicitis  and,  446 
arteriosclerosis  and,  62,  413 
associated   with   organic   dis- 
eases, 53 

better  understood,  31 
blood  lipoids  in,  100 

sugar  in,  92 

blood-pressure  and,  413 
Blight's  disease  and,  419 
caloric  needs  in,  251 
carbohydrates  in,  storage  of, 

136 

carbuncles  in,  429 
cataracts  in,  438 
in  children,  458 
complications    of,    treatment 

of,  improved,  31 
conjugal,  49 

constipation  in,  433,  475 
curability  of,  51 
danger  zone  of,  303 
death  with  coma  in,  causes  of, 

69 
without  coma,  causes  of, 

65 

diagnosis  of,  early,  29,  287 
diarrhea  in,  435 
diet  in,  carbohydrate  in,  254 

estimation  of,  259 
fat  in,  276 
protein,  267 
dietary  excesses  as  precursors 

of,  59 
duration  fifteen  years  or  more, 

468 
of  life  in,  32  et  aeq. 

statistics  of,  Boston, 

33,  34 
Joslin's,  35 
Massachusetts 
General   Hos- 
pital, 32 
Naunvn,  35 


554 


INDEX 


Diabetes  mellitus,   duration  of  life   in, 
si  at  ist  irs  of,  von  Xoor- 
den,  35 
Ions,  358 

of  elderly  people,  75 
emotional  elements  in,  01 
ether  anesthesia  in,  431 
etiology  of,  53,  (K) 

multiple,  60 
eyesight  in,  437 
fatal  eases  of  1916,  336 
food  values  in,  importance  of, 

250 

furuneulosis  in,  428 
gangrene  and,  423 
glyeosuria    most    trustworthy 

symptom  of,  148 
gout  and,  (>4 
heredity  and,  43,  2S7 

appearance  in  child  be- 
fore development  in 
parent,  44 

favorable  influence  of,  47 
in  notable  diabetic  fami- 
lies, 46 
hygiene  and  mental,  2(iO 

physical,  289 
hypophysis  and,  63 
imperfect  supervision  of,  re- 
sults of,  349 
incidence  of.  19 
in  Berlin,  22 
in  Boston,  22 
in  England,  23 
Magnus-Levy's  table  of, 

23 

in  Xe\v  York  City,  22 
in  Paris,  23 
in  Tokyo,  24 
in  United  States,  20 
in  Wales,  23 
increasing  seventy  of,  cause  of 

death,  349 
infectious    diseases    and,    62, 

288,  402 

islands  of  Langerhans  and.  76 
in  .Jewish  race.  49 
Joslin's     plan     of     campaign 

against .  304 
lime  deficiency  in.  2Sf) 
liquids  in,  2S3 
liver  and,  63 
metabolism  in,  109 

decrease  in.  1 12 
mild,  management  of,  324 
Naunyn's  conception  of,  74 
neurit  is  in,  436 
nitrogen  in,  209 
obesity  in,  53,  2SS 
in  old  age,  466 

onset  of,  frequency  of,  by  de- 
cades, 2S 


Diabetes  mellitus,  organic,  76 
pancreas  and,  63 
pathological  anatomy  of,  76 

physiology  of,  7(5 
pneumonia  and,  403 
pregnancy  and,  289,  448 
production  of,  76 
prognosis  of,  classification  for, 

299 

prophylaxis  in,  286 
pruritus  in,  427 
pulse  in,  121 
renal,  63 

respiratory  quotient  in,  117 
salt  in,  283 

severe,  management  of,  1524 
sex  and,  41 

skin  in,  care  of,  427,  474 
sodium  chloride  in,  283 
syphilis  and,  62,  292 
duration  of,  294 
teeth  in,  care  of,  431,  474 
tendency  congenital,  74 

to  increase  of,  82 
trauma  and,  62 
treatment  of,  286 

abandoned,  results  of, 347 
ambulatory,  500 

illustration  of,  306 
bananas  in,  377 
classification  for,  297 
complications  of,  im- 
proved, 31 
dietetic.  299 

general  discussion  of, 

299 

special.  364 
summary  of,  30") 
drugs  in,  399 
fasting  in,  31 1 
days  in,  364 
intermittent,  313 
case  of,  492 
preparation  for,  307 
unsuccessful  cases, 

350 

follo\v-up  methods  in.  327 
glycerin  in,  401 
hediosit  in,  402 
hospital.  493 
improvement  in,  29 
levulose    in,    experiments 

with,  37S 
of  milk  in,  299 
"  milk  cure  "  in,  377 
oatmeal,  367 
pancreatic      preparations 

in,  294 

potatoes  in,  376 
rectal   injection  of  sugar 

in.  385 
rest  in,  289 


INDEX 


000 


Diabetes     mellitus,      treatment      of, 

saccharine  in,  401 
surgery  and,  295 
surgical,  438 

elements  favoring 
success,  439 
predisposing    to 

failure,  438 
results  of,  445 
tolerance     for     carbohy- 
drate in,  317 
for  fat  in,  320 
for  protein  in,  318 
vegetable  days  in,  367 
wheat  in,  376 
tuberculosis  and,  404 
untreated,    deaths    from,    in 

1916,  342 

uterine  fibroids  and,  447 
untreated,   deaths  from,   in   1916, 

342 
Diabetic,  caloric  needs  of,  321 

conservation  of  energy  in,  398 
crockery,  251 
foods,  503 

composition  of  so-called,  519 
menus,  530 
muffins,  531 
receipts,  530 
Diabetics  above  age  of  seventy,  course 

of,  467 

Diarrhea,  435 
Dietary  and  urinary  chart,  481 

excesses  as  precursors  of  diabetes, 

59 
Diet,  composition  of,  243 

diabetic,  carbohydrate  in,  254 

estimation  of,  259 
fat  in,  276 
protein  in,  267 

knowledge  of  more  general,  30 
management  of  patients',  in  a  hos- 
pital, 498 

method  of  reporting,  477 
normal,  carbohydrate  in,  244 
fat  in,  247 
protein  in,  245 

variations  according  to  race,  245 
Dietetic  suggestions,  530 
treatment,  299 

special,  364 

Diets,  actual,  to  render  patients  sugar- 
free,  484 
Doughnuts,  510 

Drugs  in  treatment  of  diabetes,  399 
Duration  of  life,  increase  in,  25 


EDEMA,  124 
Eggs,  509 


Eggs,  variations  of,  in  weight,  249 
Emotional  elements,  diabetes  and,  61 

glycosuria,  18 

Energy,  loss  of,  in  urine,  147 
Equivalents,  table  of,  542 

useful  in  diabetic  work,  543 
Eskimo,  245,  279 
Ether,  death  from,  in  1916,  350 
Exercise,  effect  of,  144 
Expectation  of  life,  58 
Eyeball  (Riesman),  391 
Eyesight,  437 


FAST  days,  weekly,  323 
Fasting,  311 

cases  unsuccessfully  treated  by, 350 
days,  364 
intermittent,  313 
man,  metabolism  of,  149 
preparation  for  (preparatory  treat- 
ment), 307 
variations   in  weight   during  first 

week  of,  129 

Fat,  the  "built  in"  fat  of  the  tissues,  99 
danger  of,  to  diabetic,  281 
diabetic  diet,  276 
in  normal  diet,  247 
requirements  of  a  child,  461 
tolerance  for,  determination  of,  320 
value  of,  to  diabetic,  277 
Fat-protein  diet,  death  caused  by,  350 
Fatal  cases  of  1916,  336 
Fats,  cheap,  280 

influence  of,  on  weight,  125 
respiratory  quotient  for,  226 
Fehling's  qualitative  test,  175 

quantitative  test,  179 
Fermentation  test,  178 
Fibroid,  uterine,  temporary  disappear- 
ance of  sugar  after  removal  of,  296 
Fish,  509 

protein  in,  270 
Fischer  on  sodium  chloride  retention, 

128 

Flours  and  meals,  510,  519 
Folin's  test,  176 
Follow-up  methods,  327 
Food,  American,  composition  of,  508 
arranged    according    to    carbohy- 
drate content,  260 
carbohydrate  content  of,  511 

of     alcoholic     beverages, 

517 

of  animal  products,  511 
of  breads,  513 
of  cereal  breakfast  foods, 

513 

of  cereals,  512 
of  crackers,  513 


550 


IXDKX 


Food,  carbohydrate  content  of  fish  and 

shellfish,  512 
of  flours,  meals,  etc.,  .r)12 
of  fruits  and  berries,  5 1.1) 

canned,  510 
of  grapefruit,  510 
of  non-alcohol  beverages, 

510 

of  oranges,  510 
of  pastes,  513 
of  pastry,  513 
of  pickles  and  condiments, 

515 

of  vegetables,  canned, 513 
dried,  513 
fresh,  513 
of  wines,  dry,  510 

sweet,  517 
diabetic,  503 

composition  of  so-called,  510 
variations  in,  252 
Fruits,  carbohydrate  in,  204 
Furunculosis  in  diabetes,  428 


G  A  LACTOSE,  assimilation  of,  258 
Gall-stones,  00,  205 

diabetes  in  association  with,  205 
Gangrene,  diabetes  and,  423 

duration  of  diabetes  preceding,  424 

of  life  of  patients  with,  420 
treatment  of,  results  of,  427 
Gelatin,  500,  530 

Glucose,  formation  of,  from  protein, 208 
tests  for,  174 

qualitative,  175 

multiple,  177 
quantitative,  178 
tolerance  for,  250 
Glycerin,  401 

in  treatment  of  diabetes,  401 
Glycogen,  storage  of  carbohydrate  as, 

135 
Glycosuria,  alimentary,  17 

diabetes  and,  distinction  between, 

18 

most  trustworthy  symptom  of  dia- 
betes, 148 
renal,  03 

Glycuronic  acid,  184 
Gout,  diabetes  mellitus  and,  04 
Grapefruit,  carbohydrate  in,  200 


H 


HKDTOSIT  in  treatment  of  diabetes,  402 
Height  and  weight,   mortality  accord- 
ing to,  57 
Hepcocakes,  531 


Heredity,  diabetes  mellitus  and,  43,  287 

Hominy,  510 

Hospital  treatment,  403 

Household  measures,  250 

Hydrogen-ion,     concentration     of      in 

blood,  221 
Hygiene,  mental,  diabetes  and,  200 

physical,  diabetes  and,  280 
Hyperglycemia,  87 
Hypophysis,  diabetes  mellitus  and,  03 


IMPERFECT  supervision,  results  of,  340 

Inanition,  deaths  from,  08,  338 
in  1010,  338 

Infections,  deaths  from,  in  1010,  342 
intercurreiit,  death  caused  by,  352 

Infectious    diseases,    diabetes   mellitus 
and,  02,  288,  402 

Insurance,  20,  27 

Jnulin,  assimilation  of,  250 

Islands  of  Langerhans,  diabetes  melli- 
tus and,  70 


JEWISH  race,  diabetes  in,  40 
J>;slin's  plan  of  campaign  against  dia- 
betes, 304 


LABORATORY,     importance    of    physi- 
cian's, 100 
Lactose,  assimilation  of,  258 

test  for,  183 
Lecithin,  00,  08 
Lemons,  carbohydrate  in,  200 
Levulose,  assimilation  of,  258 

influence  of,   on   respiratory   quo- 
tient,  143 
test  for,  184 

in    treatment   of  diabetes,   experi- 
ments with,  .378 
Lewis-Benedict    method   of  estimation 

of  blood  sugar,  203 

Life,   average   expectation   of,    in   Ger- 
many, 20 
insurance1,  20 

diabetes  discovered  at  exami- 
nations for,   107 
policies      issued      in      I'nited 

States,  30 
rejections  on  account   of  gly- 

cosuria,  27 

Lime  deficiency  in  diabetes,  285 
Lipoids  in  blood,  test  for,  200 
Liquids  in  diabetes,  283 


INDEX 


557 


Liquids,  importance  of,  397 
Lister's  cakes,  531 
Liver,  508 

diabetes  mcllitus  and,  63 
Lobster,  509 
Lunches,  picnic,  540 
Lung,  abscess  of,  operation,  recovery, 
443 


M 


MACARONI,  noodles,  etc.,  510,  527 
Magnus-Levy's   table   of  incidence   of 

diabetes  mellitus,  23 
Maltose,  184 

assimilation  of,  258 
Meat,  protein  in,  270 
Menus,  diabetic,  530 

inexpensive,  539 

seven,  for  severe  diabetics,    with 

recipes  for  same,  535-538 
Metabolism  in  diabetes  mellitus,  109 
decrease  in,  112 

of  fasting  man,  149 

respiratorv,  total,  227 
Milk,  267,  509,  510 

carbohydrate  in,  267 
"Milk  cure''  in  treatment  of  diabetes, 
377 

respiratory  quotient  for,  185,  227 

substitutes  for,  507 

in  treatment,  290 
Miscellaneous  products,  530 
Muffins,  diabetic,  531 
Mussels,  509 
Mutton,  508 


N 


NEURITIS,  436 

Nitrogen,  determination  of,  by  titra- 

tion,  211 
in  diabetes,  209 
excretion  of,  130 
non-protein,  in  blood,  208 
tests  for,  198 
Non-carbohydrate  diets,  adaptation  of 

body  to,  154 

relation  of,  to  acidosis,  154 
Nurses,  directions  for,  476 
Nuts,  510,  511,  528 

carbohydrate  in,  264 
malted,  528 


O 


OATMEAL,  510 

carbohydrate  in,  267 
"Oatmeal  (lay,"  nutritive  value  of,  373 

influence  of,  on  respiratory  quo- 
tient, 144,  145 


Oatmeal,    plaoo     of,     in     present-flay 

diabetic  therapy,  375 
treatment,  367 
weight  of,  uncooked  and  cooked, 

375 
Obesity,  diabetes  mellitus  and,  53,  288 

prognosis  in  presence  of,  343 
Old  age,  diabetes  in,  466 
Olives,  ripe,  carbohydrate  in,  266 
Onset   of   diabetes,    frequency   of,    by 

decades,  28 
Opium  in  treatment  of  diabetes,  399, 

400,  436 

Oranges,  carbohydrate  in,  264 
Oysters,  509 


PANCREAS,  diabetes  mellitus  and,  63 
Pancreatic  preparations  in  treatment  of 

diabetes,  294 

Paradoxical  law,  Allen's,  18 
Peanut  butter,  528 
Pentose,  test  for,  184 
Peter's  test,  180 
Physiological  glycosuria,  17 
Pickles,  510 
Pie,  510 

Pneumonia,  diabetes  mellitus  and,  403 
Polariscope  test,  179 
Pork,  508 
Potatoes,  carbohydrate  in,  263 

influence  of,   on  respiratory  quo- 
tient, 143,  144 

in  treatment  of  diabetes,  376 
Poultry,  508 
Pregnancy,  conclusions,  454 

diabetes  and,  289,  448 
mild  cases,  448 
severe  cases,  449 

increase  in  tolerance  for  carbohy- 
drate during,  455 
Prognosis,  classification  for,  299 
Prostate,  removal  of,  447 
Protein  in  diabetic  diet,  267 

in  fish,  270 

formation  of,  from  glucose,  268 

in  meat,  270 

need  of  diabetic  for,  267 

in  normal  diet,  245 

preparations,  522 

requirements  of  a  child,  460 

respiratory  quotient  for,  226 

tolerance  for,  determination  of,  318 
Pruritus  in  diabetes,  427 
Pulse  in  diabetes,  121 

compared  with  normal,  122 

R 

RECIPES,  diabetic,  530 
Rectal  injection  of  sugar,  385 


558 


INDEX 


Renal  glyposiiria,  (53 
Respiration  apparatus,  clinical,  221 
examination  of,  223 

examination  of,  technic  of,  223 
Respiratory  metabolism,  total,  227 
quotient,  225 

in  diabetes,  1 17 
during  prolonged  fast,  117 
following  ingcstion  of    carbo- 
hydrate, 142 
for  alcohol,  227 
for  carbohydrate,  220 
for  fats,  22(5 
for  milk,  227 
for  protein,  22(5 
in  health,  11") 

influence  of  levulose  on,  1  13 
of  oatmeal  on.   1  14,   11.") 
of  potato  on,  143,  144 
non-protein,  229 
theoretical,  11!) 
quotients,    theoretical,    calculated 

from  diet,  230 
Rice,  ;")!() 
Rye  flour,  5 10 


S 


SACCHARINE  in  treatment  of  diabetes, 

401 

Saccharose,  assimilation  of,  258 
Salt  in  diabetes.  2S3 
Salt-free  diet,  12S 
Sausage,  508 
Scallops,  50!) 

Septicemia,  death  caused  by,  353 
Sex,  diabetes  mellitus  and,  41 
Shellfish,  509 

Skin  in  diabetes,  care  of,  427,  474 
Sodium  bicarbonate;,  avoid,  3SS 
dangers  of,  394 
influence  of,  on  weight,  127 
mode   of,    administrations    of, 

305 
chloride  in  diabetes,  283 

influence  of,  on  weight,   12(i 
relent  ion  of,  Fischer  on,  128 
Soups,  51 1 
Specific  gravity,  1 73 

fixat  ion  of,  1 7  1 
Squab.  535 
Statistics,  diabetic,  book  constructed  to 

facilitate,  501 
Sugar,  assimilability  of,  254 

in  relation  to  sugar  in  urine, 

25(5 
consumption  of,  in  United  States, 

59 

reappearance  of,  323 
rectal  injection  of,  385 
substances  in  urine  which  give  rise 
to  confusion,  1S5 


Sugar,  tost  for  use  by  patients,  475 
Surgery,  diabetes  and,  438 
Surgical  failure,  elements  predisposing 
to,  438 

success,  elements  favoring,  43!) 
Symptoms,  391 
Syphilis,  death  caused  by,  3(54 

diabetes  mellitus  and,  62,  092 


TKKTH  in  diabetes,  care  of,  431,  474 

extraction  of,  with  subsequent 

death,  431 

Trauma,  diabetes  mellitus  and,  (52 
Traumatic  glycosuria,  18 
Treatment,  abandoned,  results  of,  347 
ambulatory,  500 

illustration  of,  30(5 
bananas  in,  377 
classification  for,  297 
of  complicat  ions,  402 
dietetic,  general  discussion  of,  299 
special,  3(54 
summary  of,  305 
drugs  in,  399 
fasting  days  in,  3(54 

variations    in    weight    during 

first  week  of,  129 
of  gangrene,  results  of,  427 
glycerin  in,  401 
hediosit  in,  402 
hospital,  493 

levulose  in,  experiments  with,  378 
milk  in,  299 
'' milk  cure"  in,  377 
oatmeal,  3(17 
opium  in,  395,   100,  43(5 
potatoes  in,  37(1 
rest  in,  289 
saccharine  in,   101 
summary   of,    in    three   successive 

groups  of  cases,  328 
body  weight,  loss  of,  329 

protein,  loss  of,  335 
calories,  total,  335 
vegetable  days  in,  3(17 
wheat  in,  37(5 

Tuberculosis,  angina,  pecforis  and,   107 
deaths  from,  in  191(5,  342 
decrease  in  severity  of  diabetes  in 

presence  of,  40! I 
diabetes  mellitus  and    404 


U 


I  UINAUV  examinations,  cause's  leading 

to,  in  diabetes,  1(5(5 
inexpensive,  1(55 
routine,  29,  1(55,  1(57.  1(58 


INDEX 


559 


Urine,  chlorides  in,  test  for,  201 
collection  of,  by  patient,  475 
examination  of,  to  be  made  on  each 

birthday,  287 
mixed  twenty-four-hour  quantity 

of,  169 

reaction  of,  187 
specific  gravity  of,  173 
volume  of,  169 

Uterine  fibroids,  447 


VAX  SLYKE'S  test  for  carbon  dioxide  in 

blood  plasma,  217 
Vegetable  days,  367 
Vegetables,  carbohydrate  in,  259 

influence  of  cooking  on,  262,  263 

thrice  cooked,  533 

washed,  261 


W 


WATER  content  of  bodv,  124 
Weight,  55,  57,  123 

of  diabetic  patients,  128 
influence  of  carbohydrates  on,  125 
of  fats  on,  125 
of  sodium  bicarbonate  on,  127 

chloride  on,  126 
loss  of,  in  diabetic  patients,  128 
during  coma,  129 
prior  to  coma,  129 
variations  in,  during  first  week  of 

fasting  treatment,  129 
What  every  diabetic  should  know,  470 
Wheat,  old 

in  treatment  of  diabetes,  376 
Wishart's  test  for  acetone  in  blood,  214 


ZWIEBACK,  510 


UNIVERSITY  OF  CALIFORNIA  LIBRARY 

Los  Angeles 
This  book  is  DUE  on  the  last  date  stamped  below. 


315 


000021667 


